Maryland Baptist Aged Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 2801 Rayner Avenue, Baltimore, Maryland 21216
- CMS Provider Number
- 215360
- Inspections on file
- 15
- Latest survey
- July 17, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Maryland Baptist Aged Home during CMS and state inspections, most recent first.
Surveyors identified that staff failed to properly label, date, and track expiration of food items, with several expired or unlabeled products found in kitchen storage areas. Additionally, staff did not consistently maintain the required concentration of Quaternary Ammonium Compounds (QACs) for dish sanitization, with logs showing levels below the manufacturer-recommended range and staff unaware of the correct standards.
The facility did not have an RN on duty for 24 hours on multiple weekends and holidays, as confirmed by staffing records and the Administrator, who stated that RN coverage could not be secured for these periods.
A facility-wide assessment was found to be inaccurate, with errors in reported admission numbers, incomplete information on the facility's ability to care for residents with infectious diseases, and missing details about care for residents with tracheostomies and assistance with showers. The DON and Administrator confirmed inaccuracies and lack of staff competency verification for specialized care.
The facility's leadership failed to ensure effective oversight and implementation of the QAPI program. The QAPI plan lacked a systematic approach for identifying and analyzing problems, and the governing body did not provide adequate oversight. The DON confirmed the absence of governing body involvement, and the CFO was unaware of key issues identified by the QAPI committee, such as staff lacking CPR certification.
Facility staff did not ensure that call devices were installed in shower areas and that strings were attached to call systems in toilet stalls. Observations revealed that both the long and short hall bathrooms lacked call devices in the shower areas, and several toilet stalls were missing the necessary strings for the call systems.
Two residents were not provided with showers or opportunities to get out of bed, despite expressing a desire for these choices. Documentation in the EMR was lacking, and staff confirmed there was no way to record showers, resulting in the residents remaining in bed and not receiving showers since admission.
Staff did not provide a copy of the Notice of Medicare Non-Coverage to a resident's representative before discharge. The form lacked the representative's signature, and there was no verification that the notice was mailed or received, as confirmed by the social worker.
A resident with multiple psychiatric and behavioral diagnoses was administered several psychotropic medications without proper documentation of behavioral and mood monitoring, as required by their care plan. Staff were unable to provide the necessary monitoring records, and a pharmacy consultant's recommendation for a gradual dose reduction of one medication was not addressed. This resulted in a deficiency related to the justification and monitoring of psychotropic medication use.
Staff did not provide a resident's representative with written notification of the reasons for hospital transfers, nor did they supply a copy of the bed-hold policy at the time of hospitalization. Documentation showed only telephone notification, and staff confirmed the bed-hold policy was only given at admission.
A resident was admitted to hospice, representing a significant change in condition, but the required MDS assessment was not completed within the mandated 14-day period. The assessment was started late and remained incomplete beyond the required timeframe, as confirmed by the MDS Coordinator.
Staff did not complete and transmit a resident's MDS assessment within the required 14-day window due to delays in completing specific assessment sections. The MDS Coordinator reported that the DON and Administrator were not made aware of the issue.
Staff did not complete a narcotic count when an RN assumed control of the nursing assignment, as shown by discrepancies in the Controlled Drug Count Verification form and inability of the DON to verify completion. This resulted in a failure to meet professional standards for controlled substance management.
A resident with a left-hand contracture and hemiplegia did not receive the prescribed hand splint as outlined in the care plan, and there was no documentation of supportive device use or recent occupational therapy evaluation, despite ongoing limitations in range of motion.
Staff did not consistently provide activities to two bedbound residents who could not participate in group activities. One resident reported that in-room activities ceased after a staff member left, and activity logs showed no recent sessions for either resident. The Activities Director could not explain the lack of regular activities.
Surveyors found that medications and biologicals were not properly labeled or dated after opening, and expired medications were not removed from medication carts. Examples included undated eye drops, Nystatin powder, Duoderm gel, and blood glucose strips, as well as an expired tube of Nystatin cream, with staff confirming these deficiencies.
A resident with hemiplegia and a left-hand contracture did not receive a required Occupational Therapy evaluation or ongoing interventions after a previous course of therapy ended. The care plan called for supportive devices and splints, but no such interventions were documented or observed, and the resident reported ongoing difficulty with hand movement.
Facility staff did not have an effective system to identify, report, track, investigate, or analyze adverse events, as shown by the lack of documentation and data in the QAPI plan. The DON confirmed that while the team met monthly and discussed staffing concerns, there was no evidence of monitoring or analysis. Additionally, the facility could not provide records regarding the discovery or resolution of issues such as incomplete CPR certification among nursing staff.
Facility staff did not include the Infection Preventionist in QAPI meetings as required, with sign-in sheets lacking their name or signature and no documentation of attendance by phone. The IP could not recall their last participation, and the DON was made aware of the attendance requirement.
The facility did not maintain an adequate emergency water supply and lacked oversight of its internal water system, including failure to test for Legionella and other pathogens. Staff were unaware of their responsibilities regarding water testing and emergency preparedness, and the available water supply was significantly below recommended levels for residents and staff.
Facility staff did not apply for a required waiver for rooms that were less than the minimum square footage, despite being aware of the deficiency. When asked, the DON indicated a waiver existed, but documentation review revealed that no such waiver was available for the undersized rooms. The Administrator stated they were told not to apply for a waiver unless requested by surveyors, resulting in noncompliance.
Deficient Food Labeling and Dish Sanitization Practices Identified
Penalty
Summary
The facility failed to maintain proper labeling, dating, and expiration practices for food items, as well as to ensure correct sanitization procedures in the kitchen. During a kitchen tour, staff were unable to identify correct expiration dates on several food items, including a box of hot sauce with conflicting dates and cereal dispensers with unclear labeling. Expired spices were found, and staff could not consistently identify or date items in the freezer, with some frozen goods and a container of potato salad lacking proper labeling. Unlabeled bags of spreadable butter were also found in a freezer, and staff acknowledged the need for improved labeling practices. Additionally, the facility did not consistently meet the manufacturer-recommended range for Quaternary Ammonium Compounds (QACs) used for dish sanitization. Staff were unsure of the correct QAC concentration range, and logs showed readings below the required 200-400 ppm, with staff not recognizing that 100 ppm was insufficient for proper sanitization. These deficiencies were identified during the initial kitchen visit of the annual recertification survey.
Failure to Provide 24-Hour RN Coverage
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for 24 hours a day over a period of seven consecutive days, as evidenced by staff interviews and review of the PBJ Staffing Data Report. The report identified specific dates on which there were no RNs present for the full 24-hour period, including multiple Saturdays, Sundays, and a holiday. The Administrator confirmed during an interview that there was no RN coverage on these dates, citing an inability to secure RN staff for weekends and holidays, either from facility staff or agency sources. Additionally, review of two weeks of staffing schedules showed a consistent lack of RN coverage on weekends.
Inaccurate Facility Assessment Documentation
Penalty
Summary
A facility-wide assessment failed to accurately reflect the services provided, as discovered during a recertification survey. The assessment incorrectly documented an average of 10 resident admissions during the weekday and did not include the facility's capacity to admit residents with infectious diseases such as COVID-19, MRSA, or Clostridium Difficile. Additionally, the section regarding care for residents with conditions not listed was incomplete, and while the assessment stated the facility could care for residents with a tracheostomy, there were no current residents with this condition. The assessment also omitted showers as a form of assistance provided for activities of daily living. During interviews, the DON acknowledged that it had been some time since nurses participated in a skills lab, and there were no competencies to verify staff training for tracheostomy or gastrostomy tube care. The Administrator confirmed that the reported average of 10 admissions per week was an error.
Failure of Governing Body to Oversee and Implement Effective QAPI Program
Penalty
Summary
The facility's governing body and executive leadership failed to ensure that the Quality Assurance Performance Improvement (QAPI) program effectively identified and prioritized problems related to organizational processes, functions, and services provided to residents. During the recertification survey, it was found that the QAPI plan lacked a systematic approach for identifying, tracking, investigating, and analyzing data. The Director of Nursing (DON) confirmed that there was no oversight of the QAPI processes by the governing body. Additionally, the Administrator stated that the Chief Financial Officer (CFO) provided oversight, but could not confirm the CFO's participation or input in QAPI meetings. Further interviews revealed that the CFO was only kept informed about the QAPI process by the Administrator and DON and occasionally attended morning calls. The CFO was unable to provide details about the most recent QAPI meeting and had not reviewed the QAPI documentation. When asked about specific issues identified by the QAPI committee, such as nursing staff lacking CPR certification, the CFO was unaware of these findings. These actions and inactions demonstrate a lack of effective oversight and engagement by the facility's leadership in the QAPI process.
Missing Call Devices and Strings in Resident Bathrooms and Shower Areas
Penalty
Summary
Facility staff failed to ensure that a functioning call system was available in each resident's bathroom and bathing area. During an annual survey, it was observed that the bathroom on the long hall did not have a call device in the shower area, and the call device in the toilet stall was missing its string. Additionally, the shared bathroom on the short hall was found to be without a call device in the shower area, and two out of three toilet stalls lacked strings attached to the call devices. These deficiencies were confirmed during both the initial and subsequent tours of the facility with facility leadership.
Failure to Support Resident Choice for Showers and Mobility
Penalty
Summary
Facility staff failed to honor and facilitate resident self-determination by not providing opportunities for residents to receive showers or get out of bed, as evidenced by observations and interviews with two residents. One resident reported not getting out of bed despite wanting to, and it was observed that the only available chair in the room was used by the roommate. Both residents were observed in bed over a two-day period, and one resident confirmed not having had a shower since admission in October 2023. A review of the electronic health records and shower schedules revealed no documentation verifying that either resident had received a shower. The scheduled care indicated complete bed baths for both residents on specific days and shifts, but there was no place in the electronic medical record for staff to document showers. Staff confirmed the lack of documentation options, and the Director of Nursing was made aware of the situation, with both residents verifying the lack of showers and opportunities to get out of bed.
Failure to Provide Notice of Medicare Non-Coverage Prior to Discharge
Penalty
Summary
Facility staff failed to provide a copy of the Notice of Medicare Non-Coverage (NOMNC) to a resident's representative prior to the resident's discharge. During the recertification survey, it was found that the NOMNC form for the resident was dated and included a typed note stating that the responsible party was notified by telephone, but there was no signature from the representative to confirm receipt. Additionally, although an envelope addressed to the responsible party was presented, staff could not verify when the letter was mailed or if it was actually received. The social worker confirmed that the facility had not received a signed copy from the responsible party.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications administered to a resident were necessary and justified, as staff did not complete required behavioral and mood monitoring documentation for the conditions these medications were prescribed to treat. A resident with diagnoses including Paranoid Schizophrenia, Major Depressive Disorder, unspecified anxiety disorder, and dementia with behavioral disturbance was receiving multiple psychotropic medications, such as Quetiapine, Valproic acid, Trazodone, and Lorazepam. There was no documented indication for Quetiapine in the physician's order, and no behavior and mood monitoring documentation was found in the resident's medical record, despite care plan interventions requiring behavior monitoring every shift and documentation of behaviors and interventions. During interviews, the DON stated that behavior monitoring was done on paper and kept in the medication administration binder, but staff were unable to produce the behavior monitoring flowsheet when requested, providing only the Treatment Administration Record instead. Additionally, a pharmacy consultant had recommended a gradual dose reduction of Trazodone, but there was no documentation that this recommendation was addressed by the psychiatry provider. These findings indicate a lack of proper documentation and follow-through regarding the use and monitoring of psychotropic medications for the resident.
Failure to Provide Written Notification and Bed-Hold Policy During Resident Hospitalization
Penalty
Summary
Facility staff failed to provide written notification to a resident's representative regarding the reasons for the resident's transfers to the hospital, as required. Medical record review showed that while telephone notifications were documented for two separate hospitalizations, there was no evidence of written communication explaining the reasons for these transfers. Additionally, the facility did not provide a copy of the bed-hold policy to the resident's representative at the time of hospitalization, as confirmed by staff interviews, with the policy only being given upon admission. These deficiencies were identified during a recertification survey through review of both electronic and paper medical records, as well as staff interviews, and were specific to one resident whose records were examined for transfer and discharge practices.
Failure to Complete Timely MDS Assessment After Significant Change
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) assessment within 14 days following a significant change in a resident's condition. Specifically, a resident was admitted to hospice services, which constitutes a significant change requiring an updated MDS assessment. Record review showed that the MDS significant change assessment was initiated ten days after the resident's admission to hospice but remained incomplete more than three weeks after the significant change occurred. During a phone interview, the MDS Coordinator confirmed both the resident's admission to hospice and that the significant change assessment was still in process well past the required timeframe. The Coordinator acknowledged that the MDS assessment should have been updated within 14 days of the significant change, and that the electronic records had not been updated in a timely manner. Facility leadership and relevant staff were informed of these findings during the exit conference.
Failure to Complete and Transmit MDS Assessment Within Required Timeframe
Penalty
Summary
Facility staff failed to complete and transmit a Minimum Data Set (MDS) assessment for one resident within the required 14-day timeframe. Record review showed that the assessment reference date was 04/05/25, but the assessment was not signed until 04/25/25, which exceeded the allowed window for completion and transmission. During an interview, the MDS Coordinator explained that the delay occurred because staff responsible for completing Section E and Section Q did not do so in a timely manner. The MDS Coordinator also stated that neither the Director of Nursing nor the Administrator were informed about the difficulties in obtaining timely completion from staff.
Failure to Complete Narcotic Count During Shift Change
Penalty
Summary
Facility staff failed to complete a narcotic count when a registered nurse assumed control over the nursing assignment, as evidenced by a review of the Controlled Drug Count Verification form. On multiple shifts, the signatures of incoming and outgoing nurses did not match, and it could not be verified that the narcotic count was completed when a different nurse took over the shift. During an interview, the Director of Nursing was unable to confirm that the narcotic count was performed when a nurse assumed control of the assignment, indicating a lapse in following professional standards of practice for controlled substance accountability. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Apply Prescribed Hand Splint for Resident with Contracture
Penalty
Summary
Facility staff failed to ensure the use of a hand splint for a resident with a left-hand contracture and hemiplegia, as specified in the resident's care plan. The care plan, which was last revised in October 2024, required staff to assist with the application of supportive devices, including splints, and to perform skin checks every shift. However, during multiple observations, the resident was seen without a splint or any supportive device on the affected hand, and there was no documentation of such interventions in the Treatment Administration Record (TAR). Additionally, the resident had not received any occupational therapy screening or evaluation since August 2024, despite ongoing limitations in range of motion as documented in the Minimum Data Set (MDS) assessment. The lack of follow-up therapy and absence of the prescribed supportive device indicate that the facility did not implement the care plan interventions intended to maintain the resident's ability to perform activities of daily living.
Failure to Provide Activities to Bedbound Residents
Penalty
Summary
Facility staff failed to consistently provide activities to residents who were unable to participate in communal activities, as evidenced by record review and interviews. Two residents who were bedbound did not receive regular in-room activities; one resident reported that a staff member previously provided activities in their room, but this stopped when the staff member left. Activity logs for both residents showed no documented activity sessions for several weeks prior to the survey. The Activities Director was unable to explain why these residents were not receiving regular activities.
Improper Medication Labeling and Storage
Penalty
Summary
Surveyors identified that medications and biologicals were not properly labeled or dated once opened, and expired medications were not removed from medication carts. During observation, two eye drop medications for one resident and another eye drop for a second resident were found opened without dates on one medication cart. On another cart, two bottles of Nystatin powder and two tubes of Duoderm Hydroactive gel for a resident were also found without labels or dates. Additionally, a canister of blood glucose strips was found without an opening date. Further review revealed an expired tube of Nystatin cream for another resident still present in the medication cart. These findings were confirmed by staff present during the observations.
Failure to Provide Required Occupational Therapy Evaluation and Interventions
Penalty
Summary
A deficiency was identified when a resident with hemiplegia affecting the left non-dominant side and a left-hand contracture did not receive an Occupational Therapy (OT) evaluation as required. The resident was previously seen by OT from April to August of the prior year for activities of daily living and fall risk, but there was no documentation of any further OT screening or evaluation after that period. The Minimum Data Set (MDS) quarterly assessment indicated a limitation in the range of motion of the upper and lower extremity on one side, and the care plan included interventions such as the use of supportive devices and splints for the left hand contracture. Despite these documented needs, there was no evidence in the medical record or Treatment Administration Record (TAR) of ongoing treatment or intervention for the contracture after August of the previous year. Observations confirmed that the resident was not using a splint or any supportive device on the affected hand, and the resident reported being unable to completely open the hand. The lack of follow-up OT evaluation and absence of prescribed interventions contributed to the facility's failure to provide specialized rehabilitative services as required.
Failure to Implement Effective QAPI System for Adverse Event Monitoring
Penalty
Summary
Facility staff failed to implement an effective system for identifying, reporting, tracking, investigating, and analyzing adverse events, as determined during a recertification survey. The QAPI plan was found to lack a systematic approach for problem identification and data analysis. During interviews, the DON stated that the QAPI team met monthly and focused on staffing concerns, but could not provide documentation or data to demonstrate monitoring or analysis of staffing issues. Additionally, when asked about the process for addressing the lack of CPR certification among nursing staff, the facility was unable to provide documentation regarding when the issue was discovered, how it was being monitored, or what actions were taken to address it. Requested data and records were not available for review in the QAPI documentation.
Infection Preventionist Not Documented as Attending QAPI Meetings
Penalty
Summary
Facility staff failed to include the Infection Preventionist (IP) in the Quality Assurance Performance Improvement (QAPI) meetings as required. Record review of QAPI meeting sign-in sheets for several dates showed that the IP's name or signature was not present. During a telephone interview, the IP confirmed not attending the meetings in person but stated they participated via telephone, although there was no documentation of their attendance either in person or by phone. When asked, the IP could not recall the last time they participated in a meeting. The Director of Nursing was informed of the requirement for the IP to attend QAPI meetings and acknowledged understanding of this requirement.
Failure to Maintain Emergency Water Supply and Water System Oversight
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program by not ensuring an appropriate emergency water supply and by lacking knowledge and oversight of the building's water system. During interviews, the Director of Maintenance was unaware that the facility was responsible for testing the internal water system for Legionella and other waterborne pathogens, stating that no such testing had been conducted during his two-year tenure. Additionally, he reported that aerators in residents' rooms had not been changed and that plumbing maintenance was only performed in response to emergencies, not as part of routine preventive measures. Observation in the basement revealed only 11 five-gallon containers of water and 4 empty containers, which was significantly below the recommended emergency water supply of one gallon per person per day for three days, given the facility's capacity of 29 residents and 10 staff per day. The Director of Maintenance confirmed that the emergency water supply was used for daily operations and that recent deliveries from the contracted water supplier were insufficient. Staff were unaware of the required emergency water supply amount, and no documentation or diagrams of the water system were available.
Failure to Obtain Waiver for Undersized Resident Rooms
Penalty
Summary
Facility staff failed to apply for a required waiver for resident rooms that were less than the minimum square footage mandated by regulations. During the annual survey, the surveyor inquired about existing waivers at the entrance conference, and the DON stated that a waiver existed for undersized rooms. However, upon review of documentation, it was found that certain rooms did not meet the required square footage, and no waiver was available for these rooms. The Administrator explained that they were instructed not to apply for a waiver unless specifically requested by the survey team, resulting in the waiver not being available prior to the survey and leading to noncompliance.
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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