Mountain City Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Frostburg, Maryland.
- Location
- 48 Tarn Terrace, Frostburg, Maryland 21532
- CMS Provider Number
- 215277
- Inspections on file
- 18
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Mountain City Rehab Center during CMS and state inspections, most recent first.
Failure to Provide Required Transfer and Bed-Hold Notices: Two residents were transferred to the hospital, but the record did not show that care plan goals or current orders were sent with them. The chart also lacked documentation that bed hold or transfer notice information was provided to the resident or representative at the time of transfer, and the transfer notices reviewed did not include required appeal rights details or Ombudsman contact information.
A resident with chronic back pain had an active order for oxycodone 5 mg four times daily. An LPN signed for receipt of 30 oxycodone tablets from the pharmacy, but days later an RN discovered that all 30 tablets and the related administration record were missing. Review of the MAR and progress notes showed the resident did not receive several scheduled oxycodone doses because the medication was unavailable, and the facility could not account for the missing controlled drugs.
A facility failed to treat two residents with dignity when GNAs entered their rooms without knocking or asking permission before entering. One GNA entered a resident's room and later returned with a surveyor to show an indwelling urinary catheter bag without announcing her intent, and another GNA responded to a call light by entering a resident's room without knocking. The DON in training stated staff were expected to knock and introduce themselves when entering resident rooms.
A resident who was alert, oriented, and non-ambulatory was unable to independently adjust the bed because the remote bed control was not functioning. Surveyors observed the resident stuck in awkward bed positions, and the resident reported neck and back pain and said staff knew about the problem. Staff confirmed the remote had not been working properly for some time and that the resident could not change position without assistance.
Unsanitary Resident Room and Bathroom Conditions: A resident’s room and bathroom had a strong urine odor, a sticky bathroom floor with dark brown residue, brown-stained floor tiles, and a toilet bowl heavily stained with bowel movements. A RN said the odor had been present most of the time, and the interim NHA and housekeeping manager confirmed the conditions and noted the room was next for deep cleaning and stripping.
Failure to complete death in facility tracking record. A resident expired in the facility, but the MDS record showed no subsequent assessment after a completed Significant Change MDS, and the EHR displayed a red overdue death ARD notice. An MDS nurse who worked remotely said she ran a missing assessment report but missed the resident and acknowledged the failure to complete the death in facility tracking assessment.
Resident Not Included in Care Planning Process: A resident who was alert, oriented, bedfast, and dependent on staff for most self-care needs was not shown to have participated in the care plan meeting, and the record did not document that the resident declined to attend. An IDT care conference was held after one MDS, but no care plan meeting was documented after a later MDS, and the SSD confirmed the resident was not in attendance at the meeting that did occur.
A resident with ESRD on dialysis did not receive Renvela in a timely manner and staff documented doses that were not supported by the medication supply. Nursing notes showed the resident was out of the phosphate binder, an LPN borrowed tablets from another resident, and the MAR contained missed and undocumented doses. The remaining pill count did not match the documented administration, and the medication had to be reordered.
A resident at risk for skin impairment had a LAL mattress ordered with instructions to check functionality and weight settings every shift. The mattress control unit was observed set at 180 soft even though the resident’s documented weight was 110.4 pounds, and both an RN and an LPN documented the settings were correct despite the mismatch with the manufacturer’s manual.
A resident receiving continuous O2 via nasal cannula had an empty humidifier canister attached to the concentrator, and the tubing/cannula was not initialed or dated. The resident’s order required weekly changes of the tubing and humidifying bottle, but the equipment was overdue and the humidifying water was not present when observed.
A resident with ESRD received offsite dialysis three times weekly, but staff did not document required post-dialysis assessments after multiple treatments. The dialysis communication forms lacked post-treatment information from the dialysis center on one occasion, and the record also showed no post-dialysis UDA or BP documentation on several other dialysis days, despite the expectation that nursing staff complete an assessment after the resident returned.
Expired and unlabeled medications were found in two medication carts during a survey inspection. An opened laxative was past its expiration date, and several inhalers for residents had no opening dates documented even though they had discard timelines after opening. In one case, a nurse initially thought a resident was no longer on the inhaler, but the MAR showed it had been given earlier that day. The DON acknowledged the concern.
Missing COVID-19 Vaccine Documentation for Two Residents: The facility failed to offer and administer COVID-19 immunization to two residents reviewed. One resident had a phone consent on file, but the vaccine administration section was left blank with no other proof the vaccine was given. For another resident, staff recalled a discussion with the RP and a declination, but there was no declination form or other documentation showing the resident or RP received information to decline the vaccine.
Multiple residents with cognitive and physical impairments experienced repeated falls and injuries due to inadequate supervision, incomplete adherence to care plans, and insufficient investigation of incidents. One resident suffered a severe leg laceration during an improper transfer by a single staff member, while another resident with a history of falls was left unsupervised multiple times, resulting in several injuries. Staff interviews revealed gaps in supervision, documentation, and the effectiveness of interventions for high-risk residents.
The facility did not consistently report allegations of abuse, neglect, or injuries of unknown origin to the state survey agency within the required timeframe. Multiple incidents involving residents with cognitive and physical impairments, including altercations and unexplained injuries, were either reported late or not reported at all. Staff confusion about what constituted a reportable event and delays caused by waiting for corporate guidance contributed to these failures, impacting resident safety and regulatory compliance.
Multiple deficiencies occurred when the facility did not thoroughly investigate alleged abuse, neglect, or injuries of unknown origin, failed to document staff and resident interviews, and did not immediately remove an LPN accused of abuse from the premises. In several cases, incidents were not reported to the state agency or the Administrator, and required investigative steps were not followed, affecting several residents with cognitive impairment and complex medical needs.
The facility did not develop or document a written action plan to address repeated falls, despite reviewing fall incidents in QAPI meetings and recording a high number of falls among residents. Nursing staff were not involved in QAPI activities or performance improvement projects, and interventions were communicated verbally without systematic tracking or evaluation of their effectiveness.
A resident with multiple comorbidities, including cardiovascular disease and on anticoagulant therapy, experienced a fall and vomiting episodes. Nursing staff failed to communicate the fall and vomiting to the provider, only reporting elevated pulse and low oxygen saturation. This incomplete communication led to the provider making care decisions without all relevant information, as confirmed by staff and provider interviews. The resident was later found unresponsive and expired, with documentation showing that critical details were not relayed as required by policy.
A resident with significant medical and cognitive impairments was subjected to rough and verbally abusive treatment by an LPN during post-fall care, as witnessed and reported by multiple GNAs. The LPN was observed pulling and jerking the resident's arms, yelling, and forcefully removing a blood pressure cuff, actions that were corroborated by staff statements and confirmed by the facility's investigation as abuse.
A facility failed to follow its own policies for investigating, documenting, and reporting a resident-to-resident abuse incident involving two residents with severe cognitive impairment. Staff separated the residents and obtained witness statements after one resident grabbed and pushed another, but no incident report or risk management form was completed, and the event was not reported to authorities as required. Interviews revealed that staff believed the incident should have been reported, but leadership instructed otherwise, and no assessment was done to determine if the residents could remain roommates.
A resident admitted with multiple medical conditions, including a pressure ulcer and who sustained a fall with a skin tear, was inaccurately coded on the 5-day MDS assessment as having no falls and no pressure ulcers. Despite documentation and care planning addressing these issues, the MDS Coordinator did not clarify or accurately code the events, resulting in an assessment that did not reflect the resident's true condition.
A resident with multiple comorbidities and on anticoagulant therapy experienced a fall, after which staff failed to perform a thorough assessment or communicate critical information, such as the fall and vomiting, to the provider. The resident continued to receive anticoagulant medication, and changes in vital signs were not fully recognized or reported. Incomplete documentation and communication led to a lack of appropriate response to the resident's deteriorating condition, resulting in the resident being found unresponsive and expiring.
A resident with psychiatric diagnoses and a history of wandering behavior attempted to elope from the facility. Despite being deemed unable to make healthcare decisions, the resident was found in the parking garage attempting to access a vehicle. The facility failed to conduct an elopement assessment or include interventions in the care plan, contributing to the incident.
A resident with dementia and limited mobility developed four pressure ulcers due to the facility's failure to consistently implement preventative measures, such as using a pressure-reducing mattress and regular turning. The facility's documentation lacked evidence of adherence to the care plan, leading to actual harm.
The facility did not submit their Payroll Based Journal (PBJ) information to Medicare for the 3rd quarter ending June 30, 2024. This deficiency was identified during the recertification survey and confirmed by the DON and NHA, who noted that the previous owner submitted the report one day late. The issue was acknowledged by the Corporate Clinical Services President.
The facility failed to inform residents of their right to formulate an advance directive, as evidenced by the lack of documentation and follow-up for several residents. A resident had no advance directive on file, and there was no documentation indicating they were informed of their right. The social services director admitted to not discussing this right with current residents, despite facility policy. Additionally, other residents' records lacked advance directives and documentation of discussions about them, confirmed by the DON and social services director.
A facility failed to notify a primary care provider of a resident's abnormal TSH lab result, despite the resident being on Synthroid for hypothyroidism. The high TSH level was not documented or communicated to the provider until a surveyor's inquiry prompted staff to address the oversight.
The facility failed to accurately document MDS assessments for two residents, one with hearing difficulties and another in the dementia care unit. The first resident's hearing was inaccurately marked as adequate despite evidence of impairment, while the second resident's behavioral symptoms were not correctly recorded, leading to discrepancies in their care plans.
The facility failed to properly store and manage medications, including not discarding expired medications, improperly storing medicated creams, and administering discontinued Ativan to a resident. Additionally, a nurse pre-signed a narcotic count sheet, violating inventory reconciliation policies.
The facility failed to report abuse allegations and incidents in a timely manner, involving multiple residents and staff. In one case, a GNA was terminated for verbal abuse, but the incident was not reported to OHCQ. Another incident of inappropriate behavior between two residents was not initially reported. Additionally, a resident's injury and another abuse allegation were reported late. Staff confirmed these deficiencies during interviews.
The facility did not provide a summary of the baseline care plan to three residents or their representatives within 48 hours of admission, as required. The baseline care plan should include initial goals and a list of current medications. The DON stated that care plans were developed upon admission and provided during care plan meetings, but there was no documentation confirming that the residents or their representatives received copies. The Director of Clinical Operations acknowledged these findings.
The facility failed to invite two alert and oriented residents to their care plan meetings. One resident was not informed of their meeting, which included staff and a representative, while another was not invited, despite being cognitively intact. The social worker admitted to not notifying the second resident, and the Director of Nursing was made aware of these deficiencies.
The facility failed to follow physician orders and accurately assess residents, leading to deficiencies in care. A resident did not have their care plan updated to reflect a change from a cast to a brace, another resident's elopement risk was not properly assessed, and compression stockings were not applied as ordered. Additionally, bowel protocol medications were not administered, and a hospice consultation was not conducted as ordered.
The facility failed to respond promptly to resident call lights, with reports of delays up to 60 minutes. Observations showed that staff did not address call lights in a timely manner, despite being nearby. Residents expressed concerns about the call light system's functionality and response times.
A facility failed to provide a resident with advance notice of the termination of Medicare Part A coverage for skilled services. The resident received the Notice of Medicare Provider Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) on the same day services ended, not allowing time for an appeal. The social worker admitted to not realizing the discharge date, resulting in the notification being given on the day of discharge instead of three days prior.
A resident was transferred to the hospital without receiving the required written notification. The facility's policy mandates written notice for transfers, but staff confirmed that notifications were done verbally. The DON acknowledged the absence of a written notification process.
A facility failed to complete a Significant Change in Status MDS assessment within 14 days after a resident with Parkinson's disease experienced a significant decline in functional abilities. The resident's condition changed from requiring minimal assistance to total dependence on staff for ADLs. Despite these changes, the necessary MDS assessment was not completed, as confirmed by the MDS coordinator.
A facility failed to ensure staff assisted a resident with wearing eyeglasses, as observed on multiple occasions. The resident had an order for eyeglasses to be collected at bedtime and stored in the medication cart, but there was no documentation of assistance during the day. A GNA was unaware of the eyeglasses, and a nurse confirmed they were kept in the cart. After inquiry, the nurse placed the glasses on the resident, who expressed gratitude. The DON confirmed the GNA should have been aware of the glasses.
The facility failed to provide necessary devices for two residents with limited range of motion. One resident with a left foot drop was not wearing the prescribed brace due to a documentation error, while another resident with right-sided paralysis was without a splint because the order was not placed. Both cases highlight lapses in communication and documentation.
A facility failed to document reasons for administering PRN pain medication and did not adequately assess a resident's pain, including location and type, before and after medication. Despite having a care plan for pain management, the facility did not record non-pharmacological interventions or specific indications for medication use. The DON confirmed these documentation lapses.
A resident with end-stage renal disease did not have pre-dialysis vitals documented consistently, as required by the facility's procedures. Despite having a system for recording vital signs before dialysis, the facility failed to complete the necessary forms on several occasions, leading to incomplete communication with the dialysis center. Interviews confirmed that nurses were expected to document these vitals, but this was not consistently done.
The facility failed to document and carry out ordered 15-minute checks for a resident with suicidal ideation and administered Ativan without a current order to another resident with Alzheimer's and depression. The first resident's checks were not consistently documented, and the second resident was given Ativan despite the order being discontinued, leading to a fall without proper physician notification.
A facility failed to provide a resident with dementia care based on their preferences. The resident was observed without meaningful activities, and preference evaluations were marked as non-responsive. An Activities Assistant admitted to not following proper procedures for conducting interviews with cognitively impaired residents, leading to a lack of personalized care.
The facility failed to manage a resident's drug regimen by not specifying a removal time for a lidocaine patch, leading to inadequate documentation. Additionally, a resident with dementia and incontinence was improperly treated with antifungal cream instead of a barrier cream, as staff were not trained on proper cream application. These deficiencies highlight issues in medication management and staff training.
A facility failed to document specific reasons for administering a psychotropic medication and did not implement non-pharmacological interventions (NPI) before administering the medication as needed (PRN) for a resident. The medication was administered without documenting specific behaviors or attempting NPI, and there was no evidence of ongoing monitoring of behaviors or side effects. The DON confirmed these concerns.
A facility failed to keep medication error rates below 5%, with two errors observed out of 36 opportunities. An RN administered incorrect doses of Calcium with Vitamin D and Acetaminophen to two residents, differing from the prescribed orders. The RN acknowledged the discrepancies, and the DON was aware of the issue, with the error rate calculated at 5.56%.
The facility failed to meet the required staffing levels as per The Code of Maryland Regulations for Nursing Services, with deficiencies noted in April, May, October, and from September to November. Interviews with staff confirmed the non-compliance, and no additional evidence was provided to demonstrate compliance.
The facility's assessment was found to be inaccurate, as it incorrectly reported the number of beds in the Dementia unit. The assessment marked 'not applicable' for the number of beds, while indicating an average daily census of 30 beds. The DON confirmed the unit had only 22 beds, acknowledging the discrepancy but providing no further information by the survey exit.
A facility failed to maintain proper infection control during dressing changes for a resident with pressure ulcers, as a nurse did not change gloves or sanitize hands between wounds. Additionally, the laundry room lacked a physical barrier between clean and soiled areas, risking cross-contamination.
A facility failed to protect residents from verbal abuse and narcotic misappropriation. A GNA verbally abused a resident in the dementia unit, witnessed by staff and a family member, leading to the GNA's termination. In another case, discrepancies in narcotic administration records revealed misappropriation by a nurse, who was also terminated. The incidents were reported to authorities, but no documentation of staff education was found.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required transfer documentation and notifications for two residents who were sent to the hospital. Resident #6 was a long-term care resident who had lived at the facility for more than a year and was transferred to the hospital on 2/23/26, where the resident was admitted. Review of the eInteract Transfer Form and progress notes did not show that the resident’s care plan goals or current orders were sent with the resident. The medical record also did not show that a bed hold policy or written notice of transfer was provided to the resident or the responsible representative at the time of transfer. For Resident #6, the surveyor obtained bed hold and notice of transfer documents dated 2/23/26, but the Social Service Director reported they had not yet been sent to the resident’s family. The transfer notice signed by the previous NHA did not include required appeal rights information, including the name, address, and telephone number of the entity receiving appeal requests, instructions for obtaining and completing an appeal form, or the contact information for the Office of the State Long-Term Care Ombudsman. Resident #9, a long-term care resident who had lived at the facility for more than 6 months, was transferred to the hospital on 2/24/26 and admitted, but the record again did not show that care plan goals or orders were sent with the resident, and there was no documentation that bed hold or notice of transfer information was provided to the resident or representative. Staff described a transfer process that included sending orders, the care plan, advance directive, MOLST, bed hold policy, and capacity paperwork, but no documentation supported that these items were sent, and the transfer notice presented later also lacked the required appeal rights information.
Failure to Safeguard and Account for Controlled Pain Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to monitor and prevent misappropriation of a resident’s property, specifically controlled pain medication. Record review showed that a resident, in the facility since 2023, had an order dated 2/3/25 for oxycodone 5 mg four times daily for chronic back pain. On 10/27/25, an LPN (staff #24) signed a pharmacy packing slip at 9:16 PM confirming receipt of 30 tablets of oxycodone 5 mg for this resident. However, on 10/31/25, an RN (staff #25) discovered that all 30 oxycodone tablets and the administration record sheet for the resident were missing, and the facility was unable to locate the medications. Further review of the resident’s medication administration record and progress notes for November 2025 showed that the resident did not receive scheduled oxycodone doses on multiple occasions due to medication unavailability. Specifically, the resident did not receive the ordered 5 mg oxycodone doses on 11/1/25 at 12:00 AM and 6:00 AM, and on 11/2/25 at 12:00 AM and 6:00 AM, with progress notes documenting missed doses on 11/1/25 at 12:00 AM and 6:00 AM, and 11/2/25 at 12:00 AM because the medication was not available. During an interview, the acting DON reported that staff #24 continued to deny opening the plastic bag containing the drugs, but the missing controlled medications and associated documentation could not be accounted for, resulting in the resident not receiving ordered pain medication for chronic back pain during the documented times.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to treat residents with respect and dignity by not consistently knocking and requesting permission before entering resident rooms. During an observation on 3/3/26 at 6:25 AM, a GNA entered Resident #79's room without knocking, and later returned to the room with the surveyor without knocking or announcing her intent before showing the surveyor the resident's indwelling urinary catheter bag. During another observation on 3/4/26 at 9:01 AM, a GNA responded to Resident #72's call light and entered the room without knocking or asking permission before entering. The GNA later stated that she usually knocked before entering residents' rooms but confirmed that she had not done so during the observed interaction. The DON in training stated that staff were expected to knock and introduce themselves whenever they entered residents' rooms.
Failed to Provide a Functioning Bed Remote for Resident Independence
Penalty
Summary
The facility failed to provide reasonable accommodations to maintain a resident’s independence by not ensuring access to a functioning remote bed control. Resident #12 was observed in bed with the head of the bed elevated about 30-45 degrees and legs straight, and the resident reported being stuck in that position because the bed remote was not working. The resident stated that the remote had not functioned and that staff were aware but had not taken action to fix it, and the resident complained of neck and back pain from remaining in that position. On a later observation, Resident #12 was found lying flat on the back with the feet elevated higher than the head and again attempted to use the remote bed control without success. The resident was documented as alert, oriented, able to communicate needs, and non-ambulatory, requiring staff assistance to move. Staff interviews indicated the remote bed control had not been working properly for some time, that staff had to use manual controls at the foot of the bed, and that the resident could not change position in bed because the remote was malfunctioning.
Unsanitary Resident Room and Bathroom Conditions
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment in one resident room that had environmental concerns. Surveyors observed a strong urine odor in the resident’s room and bathroom, and on follow-up the odor was still present. The bathroom had a noticeable urine smell, a sticky floor, dark brown residue, two floor tiles to the right of the entrance stained brown, and a toilet bowl heavily stained with bowel movements. A RN stated the strong urine smell in the room and bathroom had been present most of the time. The interim NHA later confirmed the room and bathroom had a strong urine smell, the bathroom floor had dark brown sticky residue, and the two tiles near the entrance had brown stains, and the housekeeping manager confirmed the concerns and stated the room was next on the list for deep cleaning and stripping.
Failure to Complete Death in Facility Tracking Record
Penalty
Summary
The facility failed to ensure completion of a death in facility tracking record for Resident #44, who expired in the facility. Review of the medical record showed a Significant Change MDS assessment with an ARD of [DATE] was signed off as completed by Nurse #11 on [DATE], but further review on [DATE] did not reveal documentation of another MDS assessment after that assessment. The record showed more than four months without transmission of MDS assessment documentation, and the electronic health record displayed a red notice stating, "Death ARD: [DATE] 49 days overdue." Nursing progress notes confirmed the resident expired at 2:15 AM on [DATE]. During a phone interview on [DATE] at 3:57 PM, Nurse #11 stated she works remotely and is responsible for completing MDS assessments, reported she runs a missing assessment report, and confirmed Resident #44 had not appeared on the report yet; she stated, "I missed it" regarding the failure to complete the death in facility tracking assessment.
Resident Not Included in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident participated in the care planning process and that interdisciplinary team (IDT) care conference meetings were conducted after completion of MDS assessments. Resident #12 was alert, oriented, and able to verbalize needs, and the record showed the resident was bedfast and required staff assistance with most self-care needs, including mobility. During interview, the resident stated that he/she was not aware of the latest care plan meeting and had not been invited. Record review showed an MDS assessment completed on 1/12/26, followed by an IDT care plan meeting on 1/13/26. However, the record did not show that Resident #12 attended the meeting or declined to attend. The medical record also did not show that an interdisciplinary care plan meeting took place after the resident’s later MDS assessment dated [DATE]. The Social Services Director stated that care plan meetings were scheduled according to MDS timing and that notification letters were mailed to representatives and given to residents, but she also confirmed that Resident #12 was not in attendance at the 1/13/26 meeting and that there was no documentation showing the resident declined to attend. In follow-up interview, she reported that no care plan meeting was scheduled after completion of the later MDS.
Renvela Not Obtained or Administered as Ordered
Penalty
Summary
The facility failed to ensure a resident with ESRD who received dialysis three times a week had Renvela obtained in a timely manner and administered as ordered. The resident had an order for Renvela 1600 mg by mouth with meals for ESRD, and the MAR for January 2026 showed the medication documented as given three times daily. However, the dialysis communication book contained a nursing note stating that Pharmacare was to send the resident’s Renvela, and a nurse confirmed she wrote that note after the resident had gone several days without a supply. The nurse reported that she borrowed Renvela from another resident’s supply and then replaced it later, and she confirmed that the doses documented on 1/8/26 were borrowed from another resident. The resident’s bottle of sevelamer carbonate was labeled 1/12/26, and surveyor review with the nurse found at least 20 tablets remaining from an initial 240-tablet supply. Based on the ordered dose of two tablets three times daily, the supply should have lasted about 40 days if it began on 1/12/26, but the remaining count did not match the documented administration. The February MAR showed additional missed or undocumented doses, including two doses marked not given and one blank entry. The dialysis communication forms also included handwritten notes that the resident was out of Renvela and that Pharmacare needed to send it. On 3/6/26, a new order was entered for Renvela 800 mg, 2 tablets with meals, and the Nursing Home Administrator was informed of the concern that the medication had not been obtained in a timely manner, had not been administered as ordered, and that staff had borrowed medication from another resident.
Low Air Loss Mattress Set Incorrectly for Resident
Penalty
Summary
The facility failed to ensure that necessary equipment for pressure ulcer prevention was properly functioning and monitored for one resident reviewed for pressure ulcers. Resident #8 had a care plan focus related to a self-care deficit from a displaced fracture of the left femur and was identified as at risk for skin impairment related to dementia, a history of falls, and advanced age. The care plan and physician order both directed staff to use a low air loss mattress and to check functionality and weight settings every shift. On 03/03/26 and again on 03/05/26, the resident’s bed was observed with the low air loss mattress control unit set at 180 soft, while the resident’s most recent documented weight was 110.4 pounds. The manufacturer’s user manual provided by the facility instructed staff to determine the resident’s weight and set the control knob to the corresponding weight setting on the control unit. Despite this discrepancy, Staff #3 and Staff #4 documented that the mattress settings were correct during their respective shifts.
Respiratory Equipment Not Maintained for Resident on Continuous Oxygen
Penalty
Summary
The facility failed to maintain respiratory care equipment for a resident receiving continuous oxygen via nasal cannula. During an initial observation, the resident was receiving 2 liters of oxygen, but the oxygen tubing/nasal cannula was neither initialed nor dated, and the humidifier canister attached to the oxygen concentrator was empty and dated 2/11/26. A later observation showed the resident continued to receive continuous oxygen while the humidifying water canister remained empty. The resident’s order summary showed an attending provider’s order dated 6/28/25 for oxygen every shift and for the oxygen tubing and humidifying bottle to be changed, dated, and initialed weekly on Wednesdays. The facility’s Oxygen Administration policy stated to ensure there is water in the humidifying jar and that the water level is high enough that water bubbles as oxygen flows through. During interview, an LPN stated the humidifying water canister was overdue for a change, and the DON in training stated she expected nurses to change the resident’s canister, tubing, and humidifying water weekly before signing the task as completed.
Missing Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that staff completed a physical assessment of a resident after return from dialysis treatment. Resident #5 had end stage renal disease and received dialysis offsite three times per week under an order for Monday, Wednesday, and Friday dialysis. The resident’s dialysis communication book contained forms with sections for facility staff before transport and for the dialysis center to document pre- and post-dialysis information, including vital signs, access site status, mental status, lung sounds, edema, and pain. Review of the record showed that the dialysis center’s post-dialysis documentation was missing on 3/4/26, and nursing staff did not follow up to obtain the information at that time. Further review found no documentation that facility staff completed post-dialysis assessments on multiple dialysis days in February 2026, including no post-dialysis UDA or blood pressure documentation for several dates. Corporate nursing staff confirmed that the expectation was for nursing staff to complete an assessment after the resident returned from dialysis, but the record did not contain documentation showing that this occurred on the dates reviewed.
Expired and Unlabeled Medications Found in Medication Carts
Penalty
Summary
The facility failed to ensure medications were labeled and discarded when expired. During inspection of 3 medication carts, 2 carts contained concerns. In the cart assigned to the 100 hall, an opened bottle of Geri-Kot was found with an expiration date of 1/2026 even though it had been opened on 11/8/25. The same cart also contained Spiriva-Respimat for Resident #9 with no label or indication of when it was opened, despite instructions to discard it 3 months after inserting the cartridge, and Breo-Ellipta for Resident #71 with no opening date label, despite instructions to discard it 6 weeks after opening. In the cart assigned to the 300 hall, Resident #74's Anoro-Ellipta inhaler was found opened on 1/12/25 with instructions to discard it after 6 weeks from opening. The nurse initially stated the resident was probably not on the medication anymore, but after reviewing the MAR, confirmed it had been administered earlier that day. The interim DON was informed of the expired and unlabeled medications and stated that the consultant pharmacist inspects medication carts monthly, but not all carts, because the inspections are done at random.
Missing COVID-19 Vaccine Documentation for Two Residents
Penalty
Summary
The facility failed to offer and administer COVID-19 immunization to residents, as evidenced by the lack of documentation for two of five residents reviewed for immunizations. During an interview, the Infection Preventionist nurse explained that resident immunization records were maintained in the electronic health record and that hard copies of consents and declination forms were kept in a binder in her office. A review of the electronic health records showed that two residents had no documentation indicating that COVID-19 immunization was administered or declined in 2025. When the immunization binders were reviewed, one resident had a 2024-2025 COVID-19 consent form signed by the responsible party by phone, but the section for documenting vaccine administration, including date, site, and lot number, was left blank and no other documentation was found showing the vaccine was given. For the other resident, staff reported recalling a discussion with the responsible party and a declination of the vaccine, but no declination form or other documentation was found to show that the resident or responsible party received information to decline the vaccine. The Nursing Home Administrator was informed of the concern and acknowledged it.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by multiple incidents involving several residents. One resident, who had a history of muscle weakness, difficulty walking, and moderate cognitive impairment, required two staff for safe transfers according to their care plan and Kardex. Despite this, the resident was transferred by a single staff member, resulting in a severe laceration to the leg that required 15 sutures. The injury was caused by the resident's leg hitting an uncapped edge of the bed frame during the improper transfer. The staff member involved did not follow the care plan, and the incident was reported as an injury of unknown source before the cause was determined. Another resident with severe cognitive impairment, a history of falls, and dependence on staff for mobility experienced multiple unwitnessed falls over several months. The care plan included interventions such as keeping the call light within reach, frequent checks, and supervision at the nurses' station. However, the resident was repeatedly found alone in their room or in other areas without adequate supervision, leading to several falls, some resulting in injuries such as skin tears and a possible clavicle fracture. Staff interviews revealed that the resident was unable to use the call light effectively and could not remember instructions, yet was left unsupervised on multiple occasions. Staff also acknowledged that interventions like visual cues and education were ineffective due to the resident's cognitive status. Incident reports and post-fall investigations were often incomplete, lacking details about the circumstances leading to the falls, when the resident was last seen, and what interventions were in place at the time. Staff interviews confirmed that required documentation and witness statements were not consistently obtained, and that there was no clear assignment of responsibility for supervising high-risk residents at the nurses' station. These failures in supervision, adherence to care plans, and thorough investigation contributed to an environment where accident hazards were not minimized, directly resulting in harm and repeated incidents for multiple residents.
Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report multiple allegations of abuse, neglect, and injuries of unknown origin to the state survey agency within the required timeframe, as outlined in their own policy and federal regulations. Several incidents involving resident-to-resident altercations, injuries of unknown origin, and alleged staff abuse were either not reported at all or were reported late. In some cases, staff and leadership were unclear about what constituted a reportable event, leading to delays or omissions in reporting. For example, altercations between residents, such as one resident attempting to dump another from a wheelchair or a resident grabbing another by the shirt collar, were not reported to the state agency as required. In other cases, injuries of unknown origin, such as a resident's acute wrist fracture, were reported more than two hours after discovery, contrary to policy requirements. The report details that staff, including LPNs, RNs, and DONs, sometimes failed to recognize or escalate incidents as reportable abuse or altercations. In several instances, staff deferred to corporate guidance before submitting reports, which contributed to delays. There were also communication breakdowns, with some administrators and regional staff not being informed of incidents in a timely manner. For example, after a resident was found with a new fracture, the DON waited for corporate input before reporting, resulting in a late submission. In another case, a DON instructed staff not to report a resident-to-resident altercation, classifying it as a behavioral issue instead, despite staff concerns that it met the criteria for abuse. Residents involved in these incidents often had significant cognitive impairments, dementia, or physical limitations, making them particularly vulnerable. The lack of timely reporting prevented prompt investigation and intervention, as required by both facility policy and regulatory standards. The facility's failure to consistently recognize, document, and report these events as abuse, neglect, or injuries of unknown origin led to noncompliance with reporting requirements and affected the safety and well-being of multiple residents.
Failure to Investigate and Protect Residents Following Alleged Abuse and Injuries
Penalty
Summary
The facility failed to conduct thorough investigations and maintain evidence of investigations into multiple alleged incidents of abuse, neglect, and injuries of unknown origin. In several cases, the facility did not obtain or document staff and resident interviews, body audits, or other investigative steps as required by policy. For example, after an alleged altercation between two residents, there was no evidence of an investigation or documentation, and the incident was not reported to the state agency. In another case, a resident sustained rib fractures, but the facility's investigation lacked interviews with staff or residents and did not include body audits to rule out abuse or other causes. The facility also failed to protect residents from potential further abuse by not immediately removing alleged abusers from the premises. In one incident, an LPN accused of being rough and verbally abusive to a resident was allowed to continue working and interacting with the resident for several hours after the allegation was reported. Documentation showed the LPN continued to perform neurological checks on the resident and remained in the building until the end of the shift, contrary to facility policy requiring immediate suspension and removal of the accused staff member. Additionally, the facility did not consistently report alleged violations to the state survey agency or notify the Administrator as required. In several incidents involving resident-to-resident altercations or injuries of unknown origin, there was no evidence of timely reporting, comprehensive documentation, or assessment of all involved parties. The lack of thorough investigations and failure to follow established protocols affected multiple residents with varying degrees of cognitive impairment and complex medical histories.
Failure to Implement Effective QAPI Plan for Falls
Penalty
Summary
The facility failed to ensure that its Quality Assurance Performance Improvement (QAPI) program effectively implemented a plan to address quality deficiencies related to falls. Documentation from QAPI meetings over several months showed that falls were reviewed, and in one month, 25 falls involving 22 residents were recorded, with two residents accounting for five of those falls. However, there was no evidence in the facility's records of corrective actions being developed or implemented to address the high number of falls, nor was there documentation of a good faith effort to resolve the issue. Interviews with nursing staff revealed that they had not been involved in QAPI meetings or performance improvement projects, and their input on fall prevention was not solicited in a structured manner. Further interviews with the Director of Nursing (DON) and the Administrator indicated that while falls were discussed in meetings and some interventions, such as increased rounds, were verbally communicated, there was no written action plan or systematic tracking of interventions and their effectiveness. The DON expected a written plan with measurable goals and tools to assess outcomes, but was not involved in follow-up or action items. The Administrator acknowledged that interventions were discussed verbally and corrections were made on an individual basis, but there was no formal, documented plan to address the ongoing issue of falls.
Failure to Communicate Change in Condition and Pertinent Information to Physician
Penalty
Summary
The facility failed to ensure that staff communicated all pertinent information to a physician regarding a resident who experienced a fall and subsequent change in condition. According to facility policy, staff are required to promptly notify the resident, their attending physician, and the resident representative of any significant changes in the resident's condition, including accidents, incidents, or changes in physical or mental status. In this case, a resident with a history of dysphagia, aphasia, COPD, atrial fibrillation, cardiovascular disease, and congestive heart failure, who was also on anticoagulant medication, experienced a fall from bed and vomited twice around the time of the fall. Documentation and interviews revealed that after the fall, the nurse completed a change in condition assessment and notified a nurse practitioner (NP) about the resident's elevated pulse and low oxygen saturation, but did not communicate the occurrence of the fall or the vomiting episodes. The NP ordered laboratory tests and medication administration based on the information provided, but was not made aware of the fall or the resident's anticoagulant use at that time. Multiple staff interviews confirmed that there was an assumption among nurses that the fall had already been reported to the provider, leading to incomplete communication. The DON and other staff acknowledged that vomiting after a fall and the use of anticoagulants were significant details that should have been reported to the provider. Further interviews with the NP and the medical director confirmed that if they had been notified of the fall and vomiting, they would have considered holding the anticoagulant medication and would have asked additional questions. The lack of complete and accurate communication prevented the provider from making a fully informed decision regarding the resident's care. The resident was later found unresponsive and expired, with documentation and staff interviews indicating that critical information was not relayed to the provider as required by facility policy.
Failure to Protect Resident from Physical and Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from physical and verbal abuse by a staff member. According to facility policy, all staff are prohibited from physically, mentally, or emotionally abusing, mistreating, or neglecting residents, and are required to immediately report any such incidents. In this case, a resident with a history of cerebral infarction, dysphagia, aphasia, and other significant medical conditions, who required maximal assistance for activities of daily living, was subjected to rough and rude treatment by an LPN during an assessment following a fall. Multiple staff members, including several GNAs, witnessed the LPN being physically rough with the resident, including pulling and jerking the resident's arms, yelling at the resident to stop moving, and removing a blood pressure cuff in a forceful manner that caused it to break. Written statements and interviews from the GNAs consistently described the LPN's actions as rough, rude, and mean, with the LPN yelling at the resident and handling the resident in a way that was considered abusive by the witnesses. The resident, who had moderate cognitive impairment and was unable to move independently, was unable to verbally respond due to aphasia. The incident was promptly reported by the GNAs to another nurse, who escalated the report to the DON. The facility's internal investigation, as documented in the follow-up report, verified the allegations of abuse, with multiple staff corroborating the account of rough and verbally abusive behavior by the LPN toward the resident. The resident did not sustain serious bodily harm or injuries as a result of the incident, but the actions of the LPN constituted a failure to protect the resident from abuse as required by facility policy.
Failure to Investigate and Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to implement its policies and procedures regarding the investigation, documentation, and reporting of a resident-to-resident abuse incident. According to facility policy, all altercations, including those that may represent abuse, are to be investigated, documented, and reported to the nursing supervisor, director of nursing, administrator, and appropriate agencies. However, when an incident occurred in which one resident with severe cognitive impairment and a history of behavioral issues grabbed another resident, also with severe cognitive impairment, by the shirt collar and pushed them in a wheelchair, the required steps were not followed. Staff separated the residents and obtained witness statements, but no incident report or risk management form was completed, and the event was not reported to the state or police as required by policy. The residents involved both had significant cognitive impairments and behavioral histories. One resident had a diagnosis of cerebral infarction and exhibited physical and verbal behaviors toward others, while the other had dementia and was noted for inappropriate behaviors. During the incident, staff observed one resident holding and pulling on the other's shirt collar, with the affected resident becoming upset and crying. Staff intervened to separate the residents, but the incident was not properly documented or reported according to facility policy. Interviews with staff and administration revealed a breakdown in communication and adherence to policy. The DON and RN involved believed the incident constituted resident-to-resident abuse and should have been reported and investigated, but the former DON and regional director determined it was not an altercation and instructed staff not to report it. The administrator was not fully informed of the details and agreed that the facility did not follow its own policy regarding investigation, documentation, and reporting. Additionally, there was no assessment to determine if the residents could safely remain roommates after the incident.
Inaccurate MDS Assessment Coding for Fall and Pressure Ulcer
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident. The resident, who was admitted with a history of dysphagia, aphasia following a stroke, chronic obstructive pulmonary disease, and congestive heart failure, had a documented pressure ulcer on the coccyx and sustained a fall resulting in a skin tear to the right hand shortly after admission. Despite these documented conditions, the 5-day MDS assessment indicated that the resident had no falls since admission and no pressure ulcers. The MDS Coordinator, who completed and signed the assessment, did not accurately code these events, as confirmed by interviews and record reviews. The facility's policy required staff to certify the accuracy of each portion of the MDS, and the CMS RAI Manual provided clear coding instructions for falls and pressure ulcers, which were not followed in this case. Further review of the resident's care plan and progress notes confirmed the presence of a pressure ulcer and a fall, both of which were addressed in care planning and interventions. Interviews with the DON, MDS Coordinator, and Administrator revealed that the MDS Coordinator did not clarify the pressure ulcer information with nursing staff and failed to code the fall, despite being aware of both incidents. The inaccuracy of the MDS assessment had the potential to affect the resident's care and care planning, as the assessment did not reflect the resident's actual status.
Failure to Assess and Respond to Change in Condition After Fall
Penalty
Summary
Staff failed to accurately assess and respond to a resident's change in condition following a fall. The resident, who had a history of dysphagia, aphasia, stroke, gastrostomy tube, COPD, atrial fibrillation, atherosclerotic heart disease, and congestive heart failure, was found on the floor after a fall, had vomited twice, and was on anticoagulant therapy. Despite these risk factors, there was no evidence that nursing staff performed a thorough assessment, such as auscultating the lungs or assessing the abdomen, and critical information about the fall and vomiting was not communicated to the provider. Documentation and communication lapses were evident throughout the incident. The nurse practitioner was contacted but was not informed of the resident's fall, and the SBAR form was incomplete, omitting key details such as the fall and the resident's anticoagulant use. The resident continued to receive anticoagulant medication after the fall, and neurological checks were performed, but changes in vital signs and the significance of vomiting were not fully recognized or reported. Multiple staff interviews revealed assumptions that the provider was already aware of the fall, and there was a lack of clarity regarding who was responsible for communicating critical changes. The facility's policies required detailed assessment and prompt, complete communication with providers in the event of an acute change in condition, especially for residents on anticoagulants who experience a fall. However, these protocols were not followed. The resident's deteriorating condition, including elevated pulse, low oxygen saturation, and repeated vomiting, was not adequately addressed, and the provider was not given the necessary information to make informed decisions. Ultimately, the resident was found unresponsive and expired, with staff and providers acknowledging in hindsight that the resident should have been sent to the hospital and that the anticoagulant should have been held.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a vulnerable resident from exiting the facility unattended. The resident, who had multiple psychiatric diagnoses including paranoid schizophrenia, was admitted to the facility in December 2021 and was receiving multiple psychoactive medications. Despite having a court-ordered guardian and being deemed unable to make healthcare decisions, the resident exhibited wandering behavior and had packed belongings on several occasions, indicating a desire to leave the facility. On November 30, 2022, the resident attempted to elope and was found in the parking garage by two GNAs. The resident was attempting to gain access to a vehicle and was dressed in a hospital gown, pants, shoes, and a jacket, carrying a bag with clothing. The resident was returned to the facility without incident by staff. Prior to this incident, there was no documentation of an elopement assessment, and the care plans did not include interventions to address the potential for elopement. Interviews with staff revealed that the resident's behavior of packing belongings was known, but the resident was not considered an elopement risk. The facility's layout included a main entrance leading to a lobby and a parking garage, with access to the second floor where resident rooms were located. The doors to the parking garage were unlocked, allowing the resident to exit the building. The facility's failure to assess and address the resident's risk of elopement contributed to the incident.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide adequate care to prevent the development of pressure ulcers for a resident with multiple health conditions, including dementia and limited mobility. The resident had a history of being at risk for pressure ulcers, and there were orders in place for preventative measures, such as the use of a Medline mattress with a pump and regular turning and repositioning. However, the facility did not ensure these measures were consistently implemented. The resident's medical record lacked documentation of the use of the pressure-reducing mattress and the regular turning and repositioning as outlined in the care plan. The resident developed four pressure ulcers, which were identified during a new consult by a wound nurse practitioner. The ulcers included an unstageable ulcer and deep tissue injuries with significant slough and eschar. The facility's documentation failed to indicate the presence of these ulcers in the weeks leading up to their identification, and there was no evidence that the staff had been monitoring the functionality of the pressure-reducing mattress or adhering to the turning and repositioning schedule. Interviews with facility staff revealed inconsistencies in the use of pressure-reducing mattresses and a lack of clarity regarding the resident's care. The Director of Nursing was unable to confirm the type of mattress used prior to the identification of the pressure ulcers, and the wound nurse practitioner indicated that the wounds could not have developed in a single day, suggesting a lapse in preventative care. The facility's failure to adhere to the care plan and monitor the resident's condition resulted in actual harm to the resident.
Failure to Submit PBJ Information to Medicare
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) information to Medicare, as required. During the off-site preparation for the recertification survey, the survey team discovered that no data was submitted for the 3rd quarter ending June 30, 2024. This was confirmed during an entrance conference with the Director of Nursing (DON) and the Nursing Home Administrator (NHA), who were made aware of the issue. The DON later confirmed that the previous owner submitted the report one day late, and both the DON and NHA acknowledged the deficiency. The issue was further discussed with the Corporate Clinical Services President, who also confirmed the deficiency.
Failure to Inform Residents of Advance Directive Rights
Penalty
Summary
The facility failed to ensure that residents were informed of their right to formulate an advance directive, as evidenced by the lack of documentation and follow-up for seven out of nine residents reviewed. Resident #1, who had been living in the facility since August 2022, had no advance directive on file, and there was no documentation indicating that the resident or their representative had been informed of their right to formulate one. Interviews with the social services director revealed that she only assessed if newly admitted residents had advance directives and did not discuss this right with current residents, despite the facility's policy requiring her to do so. Similarly, Resident #31's medical record indicated the resident was capable of making healthcare decisions, yet there was no follow-up documentation regarding the initiation of an advance directive. The social worker admitted to not following up if the initial response was negative. Additionally, the medical records of Residents #82, #83, #236, #241, and #250 lacked advance directives and any documentation of discussions about them. The Director of Nursing and the social services director confirmed these findings during interviews.
Failure to Notify Provider of Abnormal Lab Result
Penalty
Summary
The facility failed to notify a primary care provider of an abnormal lab result for a resident diagnosed with hypothyroidism. The resident, who was admitted in 2022, was receiving Synthroid for the condition. A lab test for thyroid-stimulating hormone (TSH) was conducted, and the results, which were reported on 11/14/24, indicated a high TSH level of 17.98, significantly above the reference range of 0.45 - 4.50. However, there was no documentation in the medical record to show that the primary care provider was informed of this abnormal result. The resident was seen by a nurse practitioner on 11/19/24 for a follow-up after laboratory testing, but the progress note did not mention the high TSH level. It was only after the surveyor's inquiry on 11/21/24 that the facility staff took steps to address the oversight. The Assistant Director of Nursing and other staff members were unaware of the issue until it was brought to their attention by the surveyor, indicating a lapse in communication and documentation regarding the resident's lab results.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to ensure accurate documentation of Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care plans. For one resident, who had been experiencing hearing difficulties, the MDS assessment inaccurately documented their hearing as adequate, despite observations and staff reports indicating significant hearing impairment. The resident had been noted to have difficulty hearing during an observation, and their care plan had been revised to address this issue. However, the MDS assessment did not reflect the resident's actual hearing condition, as confirmed by the Director of Nursing. Another resident, residing in the dementia care unit, was inaccurately coded in their MDS assessment regarding behavioral symptoms. The MDS coordinator documented that the resident did not exhibit physical aggression, despite the electronic Treatment Administration Record (eTAR) showing an episode of physical aggression. The Director of Nursing acknowledged the discrepancy between the eTAR and the MDS assessment, indicating that the resident's behavior should have been accurately marked in the assessment. These inaccuracies in MDS documentation highlight the facility's failure to provide accurate assessments necessary for developing appropriate care plans.
Medication Storage and Controlled Substance Management Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for medication storage and labeling, as evidenced by several deficiencies observed during a survey. One incident involved an opened Fluticasone Propionate and Salmetrol inhalation powder labeled for a resident, which was not discarded after the recommended one-month period post-opening. This oversight was confirmed by a registered nurse during the inspection, and the Director of Nursing acknowledged the medication should have been discarded earlier. Another deficiency was noted when a Geriatric Nurse Assistant was observed retrieving antifungal creams from an unlocked dresser drawer in a resident's room, contrary to the facility's policy that such medications should be stored in a locked medication room. The Assistant Director of Nursing confirmed the improper storage and acknowledged the potential confusion due to the proximity of storage bins for different creams. Further inspection revealed expired and improperly stored medications in residents' rooms, which was against the facility's policy requiring medications to be locked and accessed only by nurses. Additionally, the facility failed to properly manage controlled substances, as evidenced by the administration of discontinued Ativan to a resident. The Controlled Drug Administration Record showed doses were removed without an active order, and the error was only identified after the medication was administered. The facility's policy requires discontinued controlled substances to be securely locked until destroyed, but this was not followed. Furthermore, a discrepancy was noted in the controlled substance inventory process, where a nurse pre-signed the narcotic count sheet, which was against the facility's policy for reconciling controlled medication inventory at shift changes.
Failure to Timely Report Abuse and Incidents
Penalty
Summary
The facility failed to report allegations of abuse and did not report them in a timely manner, as evidenced by several incidents involving multiple residents. In one case, a Geriatric Nursing Assistant was terminated for verbal abuse of two residents, but the facility did not report this incident to the Office of Health Care Quality (OHCQ). Additionally, the facility was aware of an inappropriate sexual behavior incident between two residents but failed to submit the initial report to OHCQ within the required timeframe. The Nursing Home Administrator and staff confirmed these deficiencies during interviews. Further deficiencies were noted in the reporting of a resident's injury and another abuse allegation. A resident's fractured pelvis was reported to the facility on a specific date, but the injury was not reported to OHCQ until several days later. Another incident involved an abuse allegation that was reported to the regional vice president and the Nursing Home Administrator but was not forwarded to the state agency within the required two-hour window. Interviews with the Director of Nursing and other staff confirmed these reporting delays and deficiencies.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to three residents or their representatives within 48 hours of admission, as required. The baseline care plan should include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services, along with a list of the resident's current medications. During a record review, it was found that the baseline care plans were not discussed with the residents or their representatives. The Director of Nurses stated that the care plans were developed upon admission and provided during care plan meetings, but there was no documentation to confirm that the residents or their representatives received copies of the baseline care plans. The Director of Clinical Operations acknowledged these findings.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite alert and oriented residents to their care plan meetings, as evidenced by the cases of two residents. Resident #52, who was admitted in October 2024 and was determined to be alert and oriented, was not aware of or invited to their care plan meeting held on October 29, 2024. The interdisciplinary care conference included staff from various departments and the resident's representative, but the resident themselves was not informed or present. This oversight was confirmed during an interview with the social services director, who did not indicate that the resident was notified or invited. Similarly, Resident #136, who was also admitted in October 2024 and had a BIMS score indicating cognitive intactness, was not aware of their care plan meeting. The social worker admitted to not inviting the resident to the meeting, which was attended by an activities aide, the social worker, and a family member. The medical record review showed a late entry note for the care plan conference, but it did not explain why the resident was not present. The Director of Nursing was informed of this issue, highlighting the facility's failure to ensure resident participation in care planning.
Deficiencies in Following Physician Orders and Assessments
Penalty
Summary
The facility failed to ensure that staff reviewed and acknowledged specialist recommendations, completed assessments accurately, and followed physician orders for several residents. For Resident #31, the facility did not update the care plan to reflect the change from a cast to a hand brace after an orthopedic consultation. The resident was observed without the brace, and staff were unaware of its location or the need for its use, indicating a lack of communication and documentation regarding the specialist's recommendations. Resident #256's elopement risk was not accurately assessed despite documentation of previous wandering behavior and a history of elopement. The resident had been admitted with altered mental status and a recent stroke, yet the elopement risk assessment did not reflect these factors. The Director of Nursing acknowledged that the assessment was not completed accurately, which contributed to the resident's elopement from the facility. For Resident #16, the facility failed to apply compression stockings as ordered by the attending provider, and incorrect documentation was made by the nursing staff. Resident #11 did not receive bowel protocol medications as ordered, despite documentation indicating the need for intervention. Additionally, Resident #83 did not receive a hospice consultation as ordered before passing away, highlighting a failure to follow through with physician orders in a timely manner.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond in a timely manner to resident requests for assistance, as evidenced by observations and interviews. On multiple occasions, residents reported extended wait times for staff to respond to call lights, with some instances taking 45-60 minutes. During a resident council meeting, concerns were raised about the call light system not functioning properly, leading to delays in response times. Specific incidents were observed where residents activated their call lights, but staff did not respond promptly, despite being in proximity to the alerts. In one instance, a resident's call light was activated for over an hour before a nurse addressed the issue, even though the nurse was seated near the call system. Another resident's call light remained on for 17 minutes without staff response, despite staff presence in the hallway. Interviews with staff revealed a lack of immediate response due to assignment issues, and the Director of Nursing acknowledged the expectation for staff to respond within five minutes, which was not met in these cases.
Failure to Provide Timely Medicare Coverage Termination Notice
Penalty
Summary
The facility failed to provide advance notification to a resident regarding the termination of Medicare Part A coverage for skilled services. Specifically, the deficiency was identified for one resident who was discharged from Medicare-covered Part A services while still residing at the facility. The review of documentation revealed that the resident was given both a Notice of Medicare Provider Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) on the same day that services ended, which was 8/7/24. This did not allow the resident adequate time to appeal the decision to end services, as the notification was not provided in advance. During an interview, the social worker (SW) responsible for the resident's case indicated that the usual practice is to provide notification forms three days prior to the end of services. However, in this instance, the SW admitted to not realizing the resident was discharging and consequently provided the notification on the day of discharge. This oversight resulted in the resident not being informed in a timely manner, thus failing to ensure the resident's right to appeal the decision to terminate Medicare coverage.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification of transfer to a resident and their representative, as required by policy. This deficiency was identified during a review of the medical records of a resident who had been residing in the facility since late 2022 and was sent to the hospital in July 2024. The review revealed no evidence of a written notification of transfer being provided to the resident or their representative. Interviews with facility staff, including the Social Services Director and an LPN, confirmed that the facility's practice was to notify residents and their representatives verbally, either face-to-face or over the phone, rather than in writing. The Director of Nursing acknowledged that there was no written notification process in place, contrary to the facility's policy, which requires written notice for transfers and discharges. This lack of written notification was discussed with the Director of Nursing, who acknowledged the concern.
Failure to Complete Significant Change in Status MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within 14 days following a significant decline in a resident's condition. This deficiency was identified for one resident who had been living in the facility since December 2022 and was diagnosed with Parkinson's disease. A review of the resident's medical records revealed a significant decline in their functional abilities, including a transition from requiring minimal assistance to total dependence on staff for various activities of daily living (ADLs). Despite these changes, the facility did not complete the required MDS assessment to document and address the resident's significant change in status. Interviews with facility staff further highlighted the oversight. The therapy manager noted that therapy interventions for the resident's contractures began in March 2023, and the resident's ambulation became limited by November 2023. The MDS coordinator acknowledged that the resident's decline was gradual and admitted to missing the completion of a Significant Change in Status MDS assessment. This oversight resulted in a failure to accurately assess and plan for the resident's care needs following their significant decline.
Failure to Assist Resident with Eyeglasses
Penalty
Summary
The facility failed to ensure that staff assisted a resident with wearing eyeglasses, which was evident for two out of three residents reviewed for vision and hearing. Specifically, Resident #31 had an order in place since October 15, 2024, for the nurse to collect the glasses at bedtime and place them in a black case in the medication cart every night shift. However, observations on November 12 and November 19, 2024, revealed that the resident was not wearing eyeglasses during the day. The resident's Minimum Data Set assessment indicated the use of corrective lenses, and the care plan addressed impaired visual function but did not include the use of eyeglasses. Further investigation showed that the November Treatment Administration Record documented compliance with the order to place the glasses in the med cart at night, but there was no documentation of assistance with wearing the glasses during the day. On November 19, 2024, a Geriatric Nursing Assistant (GNA) assigned to the resident was unaware of the eyeglasses, and a nurse confirmed that the glasses were kept in the medication cart. After the surveyor's inquiry, the nurse retrieved the glasses and placed them on the resident, who expressed gratitude. The Director of Nursing confirmed that the GNA should have been aware of the glasses.
Failure to Provide Prescribed ROM Devices for Residents
Penalty
Summary
The facility failed to provide appropriate care for residents with limited range of motion, as evidenced by the cases of two residents. Resident #16, who had a left foot drop, was observed without the prescribed brace on multiple occasions. Despite an order from the attending provider for the resident to wear a brace every shift, the resident reported not having worn the device for weeks. Interviews with staff revealed a breakdown in communication and documentation, as the order was not visible in the electronic health record, preventing nurses from applying the brace as required. Similarly, Resident #40, who had right-sided paralysis due to a stroke, was observed without a splint or palm protector to prevent contractures. Although a specialized hand splint was discussed and an order was placed, the Director of Rehabilitation admitted to not having ordered it, leaving the resident without necessary intervention. The Treatment Administration Record and care plan for this resident also lacked documentation for the use of a splint or other preventive measures, further indicating a lapse in care.
Inadequate Documentation of Pain Management
Penalty
Summary
The facility failed to consistently document the reasons for administering as-needed (PRN) pain medication and did not adequately document pain assessments for a resident with chronic back pain. The resident had been residing in the facility since December 2022 and had a care plan for pain management that included both pharmacological and non-pharmacological interventions. Despite this, the medical record review revealed that the facility did not document the location and type of pain, nor did it record the non-pharmacological interventions attempted before administering PRN pain medication. Additionally, the specific indications for administering the medication were not documented. The medication administration records showed that the resident received Hydrocodone-Acetaminophen for various pain levels, but there was a lack of documentation regarding pain assessments before and after medication administration. The records also failed to show continued pain management efforts after administering the medication. The Director of Nursing confirmed these concerns, stating that nurses were expected to attempt non-pharmacological interventions before administering PRN medications and should have recorded the reasons for administering the medication along with pre and post-pain assessments.
Failure to Document Pre-Dialysis Vitals
Penalty
Summary
The facility staff failed to obtain and document pre-dialysis treatment records for a resident with end-stage renal disease who required hemodialysis. The resident had a hospital discharge summary indicating the need for dialysis three times a week. Despite having a system in place for documenting pre-dialysis vitals and conditions, the facility did not record these vitals on several occasions, including specific dates in October and November. The dialysis communication forms, which were supposed to be filled out entirely and sent with the resident, were incomplete, lacking vital signs and other necessary information. Interviews with facility staff revealed that nurses were expected to record the resident's temperature, pulse, respiration, and blood pressure before dialysis and complete the communication form. However, this was not consistently done, as evidenced by feedback from the dialysis center noting the absence of pre-dialysis information. The Director of Nursing confirmed the expectation for nurses to assess and document the resident's vitals before each dialysis session, highlighting a lapse in following established procedures for ensuring safe and appropriate dialysis care.
Failure to Document and Administer Behavioral Health Orders
Penalty
Summary
The facility failed to ensure that ordered 15-minute checks for suicidal ideation were consistently documented and carried out for a resident with multiple psychiatric diagnoses, including paranoid schizophrenia. Despite an order for 15-minute checks being placed on 11/10/22, the electronic health record did not reflect this order, and there was insufficient documentation to confirm that these checks were consistently performed. The Director of Nursing confirmed that such orders should be documented in the electronic health record and appear on the Treatment Administration Record. Additionally, there was no documentation indicating that the resident was seen by psychiatric services in November 2022. Another resident with Alzheimer's disease and depression was administered Ativan without a current order due to increased agitation. The Ativan order had been discontinued on 10/18/24, yet it was administered on 11/15/24, 11/16/24, and 11/17/24 without a valid order. The resident experienced a fall on 11/16/24, but the physician was not informed of the behaviors that led to the administration of Ativan. The corporate nurse was informed of the concern that the Ativan was administered without an order, and the physician was not notified of the resident's behaviors.
Failure to Provide Dementia Care Based on Resident Preferences
Penalty
Summary
The facility failed to ensure that services provided to a resident with dementia were based on their choices and preferences. This deficiency was identified during a survey where Resident #57, who was admitted in early 2023, was observed in the dementia unit on multiple occasions without any meaningful activities being provided. The resident was seen watching TV during these observations, indicating a lack of engagement in activities that align with their preferences. A review of the resident's preference evaluations revealed that the most recent evaluation, conducted by an Activities Assistant (Staff #13) on 11/6/24, showed all questions marked as 'No response' or 'non-responsive.' A similar evaluation conducted on 8/6/24 also showed the same results. Staff #13 admitted during an interview that she did not conduct the interviews correctly, as she was not informed of the proper procedure, which includes contacting family members for input when residents are cognitively impaired. This oversight led to the resident not receiving activities tailored to their preferences, impacting their well-being.
Deficiencies in Medication Management and Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not specifying a time for the removal of a topical anesthetic patch. Resident #10 had an order for Aspercreme Lidocaine External Patch 4% to be applied twice daily for pain management. However, the order did not include a specific time for the patch's removal, leading to a lack of documentation on when the patch was removed. This oversight was confirmed through interviews with staff, including a registered nurse and the director of nursing, who acknowledged that the order was entered into the electronic record without a removal time. Additionally, the facility did not provide adequate monitoring and indications for the use of biological creams for Resident #30, who was admitted with unspecified dementia and other behavioral disturbances. The resident was frequently incontinent and required treatment for Moisture Associated Skin Damage (MASD). However, a Geriatric Nurse Assistant (GNA) was observed applying antifungal cream as a barrier cream, which was not ordered for the resident. Interviews with staff, including a Nurse Practitioner and the Assistant Director of Nursing, revealed that antifungal cream was not considered a barrier cream and that GNAs were not supposed to apply medicated creams. The Medication Administration Record (MAR) showed an order for Zinc Oxide but not for antifungal cream, indicating a lack of proper medication management and training for staff.
Failure to Document and Implement Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to document the specific reasons for administering a psychotropic medication and did not implement non-pharmacological interventions (NPI) before administering the medication as needed (PRN) for a resident. The medical record review for the resident showed orders for antianxiety medication to be administered every 8 hours PRN for anxiety, and later, twice daily for anxiety/agitation. The medication administration record (MAR) indicated that the PRN antianxiety medication was administered on specific dates, but the post-medication assessments stated the medication was ineffective. The review did not show documentation of the specific behaviors for which the medication was administered, nor any NPI attempted before administering the medication. Additionally, there was no evidence of interventions implemented when the medication was deemed ineffective, nor ongoing monitoring of changes in behaviors or side effects related to the medication use. The director of nursing confirmed these concerns and stated that the expectation was for nurses to attempt NPI before administering the medication as needed.
Medication Error Rate Exceeds 5% During Administration
Penalty
Summary
The facility failed to maintain medication error rates below 5% during a medication administration task, as observed by a surveyor. Specifically, two errors were identified out of 36 medication administration opportunities. The first error involved a registered nurse (RN) administering a tablet of Calcium 600 mg with 10 mcg of Vitamin D to a resident, whereas the medical record indicated the order was for a tablet of Calcium 600 mg with 200 mg of Vitamin D. The second error occurred when the same RN administered two tablets of Acetaminophen 500 mg to another resident, despite the medical record showing an order for only one tablet of 500 mg. The RN acknowledged the discrepancies upon review and confirmed that the administered doses did not match the prescribed orders. The RN mentioned that the Calcium with 10 mcg of Vitamin D was what the facility had in stock, and she believed the second resident was supposed to receive two tablets of Acetaminophen due to severe back pain, although the order was for one tablet. The Director of Nursing was aware of the medication errors and acknowledged the concern, with the facility's medication error rate calculated at 5.56%.
Facility Fails to Meet Staffing Requirements
Penalty
Summary
The facility failed to comply with The Code of Maryland Regulations for Nursing Services - Staffing, which mandates a minimum of 3 hours of bedside care per occupied bed per day. This deficiency was evident in the facility's staffing data for several months. Specifically, during April and May 2023, the facility did not meet the required staffing levels on 16 out of 61 days. Similarly, in October 2023, the facility's PPD was below the required 3.0 for 9 out of 31 days. Furthermore, from September 1, 2024, to November 14, 2024, the facility only met the required staffing levels on three days, with the PPD falling below 3.0 on 38 out of 75 days. Interviews with facility staff, including the Staffing Coordinator, Director of Nursing, Assistant Director of Nursing, and Corporate Nurse, confirmed the deficiency in staffing levels. The facility's staff acknowledged the non-compliance with state regulations and indicated awareness of the issue. Despite being aware of the deficiency, no additional evidence or information was provided to demonstrate compliance with the required staffing levels. The facility's failure to maintain adequate staffing levels as per state regulations was a consistent issue over the reviewed periods.
Inaccurate Facility Assessment in Specialty Unit
Penalty
Summary
The facility failed to maintain an accurate and complete facility-wide assessment, which is crucial for determining the necessary resources to care for residents competently. During a review conducted by a surveyor, it was found that the facility marked 'not applicable' in the section regarding the number of beds in the specialty unit, despite indicating an average daily census of 30 beds in the same unit. Upon further investigation, the Director of Nursing (DON) confirmed that the facility was licensed for a specialty unit, specifically a Dementia unit, which actually had only 22 beds. This discrepancy was acknowledged by the DON, who stated she would investigate further, but no additional information was provided by the time of the survey exit.
Infection Control Deficiencies in Dressing Changes and Laundry Room
Penalty
Summary
The facility failed to ensure proper infection control practices during dressing changes for a resident with pressure ulcers. The resident, who has been residing at the facility for several years and has a diagnosis including dementia, had two unhealed pressure ulcers on both feet. On a specific date, a nurse was observed performing dressing changes on the resident's wounds. The nurse sanitized hands and donned gloves before starting the procedure but did not change gloves or perform hand sanitation between changing the dressings on the right and left foot. This lapse in protocol was confirmed by the nurse during an interview. Additionally, the facility's laundry room was found to lack a physical barrier between the clean and soiled areas, which is necessary to prevent cross-contamination. During a tour of the laundry room, an opening was observed between these areas without any door or barrier. The director of environmental services acknowledged the issue, and the assistant director of nursing and infection prevention nurse confirmed that the facility's newer ownership was aware of the concern.
Verbal Abuse and Narcotic Misappropriation in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal abuse and misappropriation of narcotics, as evidenced by incidents involving two residents. In the first case, a Geriatric Nursing Assistant (GNA) verbally abused a resident in the dementia unit by calling them derogatory names. This incident was witnessed by other staff members and a family member of another resident. The GNA admitted to the verbal abuse during an interview with the former Nursing Home Administrator, Director of Nursing, and Human Resources Director, leading to their suspension and termination. In the second case, discrepancies were found in the administration of narcotic medication to a resident. The facility's records showed inconsistencies between the electronic Medication Administration Record (eMAR) and the written sign-out sheet for Oxycodone/APAP, a controlled substance prescribed for the resident's knee pain. The resident reported not receiving the medication as documented, and a review revealed that Nurse #50 had removed more doses than were recorded as administered. This discrepancy suggested misappropriation of narcotics by the nurse, who was later terminated. The facility's investigation into the narcotic misappropriation included witness statements from nursing staff and the resident, confirming the discrepancies in medication administration. The incident was reported to local authorities and the Drug Enforcement Agency (DEA). Despite the Assistant Director of Nursing's claim of conducting staff education following the incident, no documentation was found to support this claim.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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