Oakwood Snf Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Middle River, Maryland.
- Location
- 1300 Windlass Drive, Middle River, Maryland 21220
- CMS Provider Number
- 215181
- Inspections on file
- 19
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 59
Citation history
Health deficiencies cited at Oakwood Snf Llc during CMS and state inspections, most recent first.
Failure to Offer Advance Directives: The facility did not ensure residents were offered the opportunity to formulate advance directives. Survey review found missing documentation for multiple residents, including capable residents and those admitted without evidence that ADs were discussed or offered. The Social Services Director could not produce records showing the offer was made, and several charts only showed code status or no AD information at all.
The facility failed to submit monthly transfer and discharge notices to the Ombudsman. During survey, the Administrator confirmed that the required notices had not been sent and stated they had not been submitted since she began working at the facility in September 2025.
A resident’s right to self-determination was not honored when fasting blood sugar checks were scheduled for 6:00 AM, causing repeated refusals because staff were waking the resident between 5:00 AM and 6:00 AM. The resident said the concern had been shared multiple times, but the DON and Endocrinology NP were unaware of the reason for the refusals until the surveyor informed them. Bedtime blood sugar checks were largely completed as ordered.
Unsanitary Storage of Toilet Plunger in Resident Bathroom: A surveyor observed a toilet plunger stored in a plastic bag next to the toilet in a resident bathroom, with a brown liquid substance coating the bottom of the bag. The Maintenance Director confirmed that plungers should not be kept in soiled plastic bags in residents' bathrooms.
A resident had an active PRN order for Hydroxyzine 10 mg q12h for anxiety that remained in place beyond the 14-day limit without a provider-documented rationale. The DON stated PRN psychotropic orders should be limited to 14 days unless the provider documented the extended need, and the facility policy reflected the same requirement.
Failure to provide a baseline care plan summary to a resident was identified during record review. Documentation showed that a baseline care plan had been initiated, but there was no record that it was reviewed or that a copy was given to the resident or the responsible party, and the DON was unable to locate proof that it had been provided.
Failure to hold quarterly care plan meetings for multiple residents. Interviews and record review showed several residents either did not know when their last care plan meeting occurred, had no documentation of a recent meeting, or reported never participating in one. In one case, a scheduled meeting was missed because the resident was at the hospital, and the record did not show it was rescheduled and completed.
Medication administration was not provided according to physician orders for two residents. One resident with opioid dependence received Oxycodone outside the ordered pain parameters on multiple occasions, and another resident ran out of Pregablin because a refill was not requested before the medication supply was exhausted; the MAR also showed delayed Pregablin doses without documentation that the physician was contacted for guidance.
Failure to follow up on hearing assessment recommendations: A resident reported difficulty hearing and said they had previously been told they were a candidate for hearing aids, but there was no documented follow-up. The surveyor observed the resident speaking loudly, and the medical record did not show a hearing assessment. A later hearing evaluation documented moderate to severe hearing loss in both ears, recommended clear slow speech with visual cues, and stated the resident was a candidate for hearing aids, but the DON said there was no documentation that the physician had been notified.
Failure to provide scheduled hygiene assistance: Two residents reported and records showed missed or inconsistent shower care. One resident said he/she waited a long time to be cleaned up, and the DON could not find documentation that showers were offered or provided on two scheduled shower days. Another resident stated showers were only offered once weekly despite a twice-weekly schedule, and the UM confirmed the chart showed only one shower per week with no refusals documented.
The facility failed to provide appropriate insulin administration and provider notification for two residents with abnormal blood glucose levels. One resident’s mealtime Humalog was not given as ordered, and subsequent BG readings rose to 400, 411, and 449 mg/dL; the record did not show that the provider was called for readings over 400. Another resident had multiple bedtime BG readings up to 410 mg/dL, but the chart did not document physician notification despite the DON stating that readings at or above 400 mg/dL should be reported.
A resident reported requesting a hearing screening but still waiting for a hearing test, and the medical record lacked documentation of any hearing appointment or consultation. The DON later acknowledged the facility failed to submit the required audiology paperwork to the outside consultant, so the resident did not receive the hearing screen.
A resident with a contracted left hand was observed multiple times without the prescribed splint in place, with the splint left on the bedside table or floor. The chart contained two conflicting left-hand splint orders, while the TARs documented both as completed. OT discharge notes called for palm guard use at all times, and the DON stated the most recent recommendation should be active and the TAR should reflect the care provided.
A resident who required enteral nutrition did not receive appropriate care when a water hydration bag remained in use beyond the expected 24-hour change interval and was relabeled instead of replaced. The acting DON stated that both the tube feeding and water bags should be changed every 24 hours, and the facility policy required administration sets to be changed every 24 hours and labeled with the date and time of change.
The facility failed to have a clearly designated night shift supervisor and failed to have enough staff to administer medications on time. An LPN and another LPN were unaware of who was supervising the night shift, and the staffing sheet did not list a night supervisor for that shift. During medication pass, an LPN had to stop for resident care, a call light, and a lab specimen before starting meds, causing delays; some 8:00 AM medications were not given until 9:40 AM.
Failure to post required staffing information was identified when the front desk staffing tray was empty and the nurses' station assignment board was blank. An LPN was unsure who the night shift supervisor was, stated the board had been wiped clean for a new assignment, and said there may not have been a nighttime supervisor. The acting DON confirmed the staffing should have been posted.
Medication Administration Error: An LPN prepared and administered only one 150 mg bupropion ER tablet to a resident even though the order required three tablets once daily. The error was identified during observation and order review, and the LPN later stated she had not realized the full dose was not given.
A resident had duplicate orders for Vitamin D 1000 units, creating two MAR entries that appeared to require two doses even though an LPN administered only one tablet. The LPN noticed the duplicate order but had not yet contacted the provider, and the DON stated the order had been entered once with two routes checked in error, causing it to appear twice on the MAR.
A medication cart in the hallway was left unsecured and accessible while a CMA was away from it. The cart contained resident meds, floor stock meds, and a personal water bottle, and the CMA confirmed she should have locked the cart before leaving it unattended and should not have stored personal items in it. The DON stated staff should have their own keys and carts must be locked when unattended.
A facility failed to ensure timely dental services for two residents. One resident had repeated reports of tooth pain, provider notes documenting a pending dental consult, and only later had a dental appointment arranged by family. Another resident reported needing dentures, and MDS assessments showed obvious or likely cavity or broken natural teeth, but the Administrator could not find documentation of any follow-up dental care.
Meals were not served according to the menu or resident preferences. During tray observations and resident interviews, residents reported receiving foods different from what was listed on their meal tickets, including scrambled eggs and toast instead of sausage gravy on biscuits, missing cottage cheese, and breakfast trays that lacked listed alternative meats. A GNA stated the kitchen did not update tickets when foods were unavailable and that residents often received items listed in their dislikes.
Two residents reported that meals were served cold and staff were too busy to heat them up. Staff gave inconsistent answers about reheating trays, with one GNA saying staff were not allowed to heat food, the DON saying trays should be returned to the kitchen, and another GNA saying she used a microwave in the break room. The FSD also reported frequent complaints about cold food and noted that one side of the plate warmer was broken.
Missing Assistive Eating Devices: A resident with a physician order for a weighted spoon and fork was observed eating with a standard fork while the hands visibly shook and food fell from the utensil. The resident indicated the facility did not provide assistive utensils. Staff said devices should be identified on the meal ticket and placed on the tray, and the Administrator and DON acknowledged the concern about the missing utensils.
Unsafe food storage and labeling practices were observed in the kitchen, including expired sandwiches in the refrigerator, spices without labels or dates, unlabeled food in the freezer, and ice buildup on frozen items near the compressor. The FSD also identified ham in the walk-in refrigerator that should have been discarded after 7 days, and the Administrator acknowledged the kitchen concerns.
Incomplete PASARR Documentation: A resident’s record showed a PASARR level I indicating a need for a level II screen, but the chart did not include documentation of a completed level II PASARR or a determination that one was not required. The DON and DOSS stated the level I had been filled out incorrectly, and there was no indication AERS had been informed or had made a level II determination.
Improper Storage of Clean Linen on Hallway Carts: Linen carts on multiple hallways contained non-linen items, including dirty equipment, briefs, trash bags, cups, toiletries, basins, and other resident care supplies. The DON stated linen carts should only contain clean linen, and a clean linen cart on another hallway was observed with its front cover left up, exposing the linen inside.
Kitchen equipment was not maintained in safe operating condition. The surveyor observed ice buildup and dripping from the walk-in freezer compressor, a broken side on the plate warmer that was linked to complaints about cold food, and a broken hot water heater that prevented safe dishwashing. Staff and the Administrator acknowledged the equipment problems and described ongoing repair efforts, while a later dish machine check showed wash and rinse temperatures of 142 and 186.
Call System at Nurses' Station #3 Was Not Functioning Properly. The facility failed to ensure the resident call system was working properly at one nurses' station, where the panel continuously beeped every few seconds even when no resident calls were active and no room numbers appeared on the screen. RN staff stated the issue had been ongoing and maintenance had already looked at it, while the Maintenance Director later confirmed the abnormal beeping and noted other stations did not have the same problem.
The facility failed to ensure staff received required abuse, neglect, and exploitation training for 2 of 6 employee files reviewed. The DON said competencies are checked at orientation and annually and that Relias is used for monthly and annual training, but the files for a GNA and an LPN did not show evidence of the required annual abuse training, and the DON acknowledged the 2025 training was not completed.
Missing QAPI Training for Staff: The facility failed to ensure required QAPI training was completed for three staff members. Record review showed the facility assessment identified QAPI as a required training topic, but the files for two GNAs and an LPN did not contain evidence of QAPI training, and the DON acknowledged the annual training had not been completed.
The facility failed to ensure infection control training was completed for three staff members. The DON stated that annual competencies and required training are tracked through Relias, but review of employee files showed no evidence of infection control training for two GNAs and an LPN, and the DON acknowledged the annual training had not been completed.
Missing compliance and ethics training was identified after record review and DON interview. The facility assessment listed compliance and ethics as a required staff training topic, but the files for two GNAs and an LPN showed no evidence of the required annual training. The DON acknowledged that the annual training had not been completed for those staff members.
Facility staff failed to accurately code falls on the MDS for several residents. One resident had two falls during the look-back period, including one with a scalp laceration requiring staples, but only a single fall without injury was coded. Another resident had two documented unwitnessed falls to the floor near the bed with no injuries, yet only one fall without injury was recorded on the MDS. Additional residents had documented falls, including one during a transfer attempt and another reported by a housekeeper after the resident coughed and sat on the floor, but their MDS assessments indicated no falls. The MDS Coordinator acknowledged these omissions during interviews, and the concern was reported to the Nursing Home Administrator.
Surveyors observed that a resident room was not maintained in a safe, clean, and comfortable condition. Trash, including wrappers, tissues, a hair brush, and food, was scattered on the floor, with leftover food and crumbs on both residents’ bedside tables and stuck-on food on a wheelchair cushion. The floor mat and room corners were dirty and dusty. When shown these conditions, the charge nurse noted that the resident is a messy eater, but the roommate’s side of the room was also unclean, demonstrating a failure to adequately clean and maintain the shared room environment.
A resident with adult FTT developed a new skin condition on the buttock that was later assessed by a wound physician as a Stage III pressure ulcer, with an order for daily Calcium Alginate dressing. Review of documentation showed staff continued using wound cleanser and did not implement the ordered Calcium Alginate treatment for several days until the order was changed to zinc ointment every shift. The Regional Director of Clinical Operations confirmed that the ordered pressure ulcer treatment was not provided as directed.
Facility staff failed to follow dietitian recommendations and physician follow-up for two residents with weight loss and malnutrition. For one resident with dementia, FTT, and mild protein-calorie malnutrition, staff did not obtain or file results of an ordered GI telehealth consult and missed one of the weekly weights ordered by the dietitian. For another resident with malnutrition, staff obtained only two of four recommended weekly weights, and the dietitian did not reassess the resident after the initial evaluation. These inactions resulted in incomplete monitoring and follow-up for residents identified as experiencing weight loss.
A resident with a history of goiter had a chest X-ray that showed worsening mediastinal findings and specifically recommended a CT scan, but staff did not obtain a CT in a timely manner. The CT was ordered weeks after the initial recommendation, then the scheduled test was discontinued when the imaging provider would not accept the resident on a stretcher, and no alternative arrangements were documented. Subsequent hospital imaging again recommended outpatient chest CT correlation, yet the CT was not ordered or completed until the resident was later sent back to the hospital. The Regional Director of Clinical Operations confirmed staff failed to follow up and obtain the CT over this extended period.
The facility failed to clearly post the location of its survey results book, preventing residents and visitors from easily identifying where to access survey, certification, and complaint investigation results. A surveyor found no signage in the lobby and had to ask the receptionist, who indicated the book was stored in a drawer of a black table near the NHA’s office, with no sign on or near the table. A sign found on a nursing unit wall only stated that the survey book was in the front lobby and did not mention it was kept in a drawer. The NHA reported the book was kept in the drawer because a resident had previously torn it apart, and the Regional Director of Clinical Operations and receptionist were unable to locate the usual sign.
A review of grievance records revealed that the facility failed to maintain an effective grievance system, with missing forms for several months and incomplete documentation on available forms. Two residents' complaints, including missing personal items and unreturned calls, were not properly documented or resolved according to facility policy, as confirmed by interviews with the DON and Administrator.
Multiple residents were left without proper hygiene care due to ongoing shortages of clean towels, washcloths, and other hygiene materials. Staff and family members reported that residents were left in soiled briefs and unable to be bathed, with staff sometimes resorting to using bed sheets or pillowcases as substitutes. Facility staff confirmed that linen shortages were frequent and that the process for distributing and recycling linens was disorganized, resulting in inadequate care for residents.
A resident was observed walking in a hallway wearing only a hospital gown that exposed their back and shoulder, due to a lack of available clothing. Staff interviews confirmed that multiple residents lacked proper clothes and that this situation was recognized as a dignity issue by nursing leadership.
A resident dependent on staff for ADLs and diagnosed with Parkinson's Disease did not receive showers as preferred, despite a physician's order and clear documentation of this preference. The care plan failed to reflect the resident's wish for showers, and records showed only bed/towel baths were provided. Facility leadership acknowledged that resident preferences should be honored and documented.
Staff did not maintain a clean and homelike environment, as strong odors of urine and possible body odor were repeatedly observed in two nursing units. These issues were confirmed through both complaints and direct surveyor observation.
The facility did not conduct comprehensive investigations into two incidents: one involving a resident who sustained a rib fracture and pneumothorax after reporting being pushed, and another where a resident suffered a femur fracture during transport. In both cases, required documentation such as witness statements, staff interviews, and communication records were missing, and the facility was unable to provide evidence of a thorough investigation.
A resident with left-sided paralysis and weakness, who was dependent on staff for ADLs including mobility, did not have a care plan that addressed their specific mobility needs or interventions. Review of records and staff interviews confirmed the absence of a comprehensive, individualized mobility care plan.
Surveyors found that staff failed to provide timely incontinence care and regular showers for several dependent residents, with one resident waiting nearly an hour for care after a bowel movement and another left in a hallway for hours after an incontinence episode. Documentation showed that some residents did not receive scheduled showers, and staff confirmed that only a limited number of showers were available due to maintenance issues.
A resident with severe intellectual disabilities was found on the floor with a head injury and bleeding after attempting to walk to the bathroom unassisted. Staff provided immediate care and sent the resident to the hospital, but the facility's investigation did not include interviews with staff or the roommate, limiting the ability to determine the root cause of the fall.
Staff did not ensure that cold food items on a test tray, including cream cheese, milk, and apple juice, were served at or below the required 41°F, with all items found above this limit during a survey. The issue was identified for one of two test trays sampled.
A resident was served a meal tray without a meal ticket, which is necessary to confirm dietary requirements, allergies, and other pertinent information. A GNA admitted to serving the tray without proper verification, and staff interviews confirmed that trays without tickets should be returned to the kitchen for verification.
Facility staff did not maintain complete medical records for a resident with advanced osteoporosis who sustained a leg injury during transport to dialysis. The communication flow sheet from the dialysis center, which included the nurse's notes and signature about the incident, was missing from the resident's file. Staff interviews revealed gaps and inconsistencies in documentation, and the original notes from the dialysis nurse were not found in the facility's records.
Failure to Offer Residents the Opportunity to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to formulate advance directives. During the recertification survey, this was identified for 6 of 7 residents reviewed for advance directive planning, including Residents #1, #2, #90, #11, #7, and #8. On 02/25/2026, the surveyor asked the Director of Social Services for documentation showing that Residents #1, #2, and #90 had been provided the opportunity to formulate advance directives, and the Director stated he could not find such documentation. Resident #11 was admitted in April 2025 and was deemed capable of making his/her own medical decisions, but the medical record contained no documentation showing the resident was asked whether he/she wanted to formulate advance directives. Staff later stated he also could not find documentation that advance directives were offered, although he later stated he had reviewed and assisted Resident #11 in initiating advance directives. For Resident #7, the medical record did not show an advance directive or that the resident was asked about one on admission; the Social Service Initial Evaluation dated 2/28/2024 indicated the resident did not have an advance directive but did not show that information to create one was offered. For Resident #8, the medical record also did not show an advance directive or that the resident was asked about one on admission, and the Social Service Initial Evaluation dated 9/10/2025 did not indicate whether advance directives were addressed, only noting the resident's code status.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to ensure that notices of resident transfers and discharges were submitted to the representative of the Office of the State Long Term Care Ombudsman. During the annual survey, the surveyor requested documentation showing that the Ombudsman had been notified of monthly transfers and discharges from October 2025 through December 2025. The Administrator stated she would gather the information, and later confirmed that the facility had not submitted the monthly transfer and discharge notices. When asked when the Ombudsman was last notified of resident transfers and discharges, the Administrator stated that notices had not been submitted since she began employment at the facility in September 2025.
Failure to Honor Resident Preference for Blood Sugar Monitoring
Penalty
Summary
The facility failed to honor a resident’s right to self-determination by not respecting the resident’s preference for the timing of fasting blood sugar checks. Resident #4 had physician orders for fasting blood sugar monitoring daily at 6:00 AM and bedtime blood sugar checks daily at 10:00 PM. From 02/01/2026 through 02/25/2026, the resident refused 21 of 24 fasting blood sugar checks, while the bedtime checks were completed on 23 of 24 occasions. Progress notes from Nephrology, the Primary Physician, and the Endocrinology NP in January and February 2026 documented that the resident refused blood sugar checks. During interview, the resident stated the refusals occurred because staff were waking them between 5:00 AM and 6:00 AM, and the resident did not want to be awakened that early. The resident said this concern had been communicated to staff multiple times, but nothing had been done. The DON confirmed awareness of the refusals but stated she did not know the reason. The Endocrinology NP also acknowledged awareness of the refusals but stated he did not know the reason. After the surveyor informed the NP of the resident’s preference, a new progress note was entered recommending the fasting blood sugar checks be conducted at 7:30 AM per the resident’s preference.
Unsanitary Storage of Toilet Plunger in Resident Bathroom
Penalty
Summary
The facility failed to provide services necessary to maintain a sanitary environment in a resident room bathroom. During the initial tour, the surveyor observed a toilet plunger inside a plastic bag next to the toilet in room [ROOM NUMBER], and a brown liquid substance was noted coating the bottom of the bag. During an interview, the Maintenance Director confirmed that when a plunging need is identified, maintenance receives a work order to address it, and stated that plungers should not be kept in soiled plastic bags in residents' bathrooms.
PRN Psychotropic Medication Order Exceeded 14 Days Without Provider Rationale
Penalty
Summary
The facility failed to ensure that a resident’s PRN psychotropic medication order did not exceed 14 days without a provider’s documented rationale. Resident #10 had an active order for Hydroxyzine 10 mg every 12 hours as needed for anxiety, with a start date of 1/23/2026. During record review on 02/25/2026, the order was found to still be active, and on 02/26/2026 the DON stated that PRN psychotropic medication orders should be limited to 14 days unless the provider documented a rationale for the extended need. The surveyor requested and reviewed the resident’s active order and the facility’s policy titled, Antipsychotic Medication Use, which stated that PRN psychotropic medications should be limited to 14 days unless a provider documented a rationale for the extended order. The DON reviewed the concern with the surveyor and indicated understanding.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to ensure that residents were provided with summaries of their baseline care plans. During record review for Resident #13, documentation showed that a baseline care plan was initiated, but there was no documentation that the care plan was reviewed or that a copy was provided to the resident or the responsible party. When asked for the information, the Administrator stated on 02/26/2026 at 11:46 AM that she was unable to find documentation showing that a baseline care plan had been given to Resident #13 and/or the responsible party.
Failure to Hold Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents received quarterly care plan meetings. During interviews and record review, four residents were identified as not having evidence of timely care plan meetings. Resident #7 stated that the last care plan meeting occurred during the previous summer, and the last documented meeting provided by staff was 8/6/2025. Resident #129 stated they were unaware the facility held care plan meetings and reported never participating in one at the facility; the last documented meeting provided was 9/3/2025. Resident #8’s medical record did not show when the last care plan meeting occurred, and the last documented meeting provided was 9/25/2025. Resident #16 stated they were unsure when the last care plan meeting occurred. The medical record showed a progress note dated 1/7/2026 indicating a care plan meeting was scheduled that day, but the resident was at the hospital at the time. Further review did not show that the meeting was rescheduled and completed. The last documented care plan meeting provided for Resident #16 was 7/23/2025. The Director of Social Services stated that care plan meetings were held at least quarterly after the comprehensive assessment, and the Director of Nursing later indicated understanding of the concern.
Medication Administration Not Followed as Ordered
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for two residents reviewed during the annual survey. Resident #129 had an order for Oxycodone 10 mg by mouth every six hours as needed for pain rated 7-10, but the February 2026 MAR showed the medication was given on 23 occasions when the documented pain score was 0-6. Review of the January 2026 MAR showed 24 administrations outside the ordered parameters, and the December 2026 MAR showed 17 administrations outside the ordered parameters. The DON stated that nursing staff are expected to follow the physician’s ordered parameters when administering medication and acknowledged the MAR documentation showing the medication was given outside those parameters. Resident #49 had active orders for Pregablin 100 mg by mouth twice daily at 8:00 AM and 4:00 PM and Pregablin 150 mg by mouth at 8:00 PM. During observation, an empty medication blister card was found at the nurse’s station, and the LPN stated the resident had run out of Pregablin. The LPN explained the facility’s process was to request a refill when the medication reached eight tablets, but staff had not requested the refill before the medication ran out. The MAR showed the scheduled 4:00 PM dose and 8:00 PM dose were administered late at 8:33 PM, and the record did not show documentation that the physician was contacted for guidance regarding the delayed administration.
Failure to Follow Up on Hearing Assessment Recommendations
Penalty
Summary
The facility failed to ensure that Resident #4 received services to maintain or improve the ability to perform activities of daily living related to hearing. During an interview, the resident reported difficulty hearing and stated they had been evaluated the prior summer and told they were a candidate for hearing aids, but there had been no follow-up. The surveyor observed the resident speaking loudly, which was consistent with the resident’s report of hearing loss. A review of the medical record did not reveal documentation that the resident’s hearing had been assessed. The DON later stated she believed the resident had been screened in July 2025 and said she would follow up after locating the documentation. The hearing assessment that was later provided documented newly decreased hearing, moderate to severe mixed hearing loss in the right ear, moderate to severe sensorineural hearing loss in the left ear, and a recommendation for staff to use clear, slow speech with visual cues and favor the resident’s left ear. The assessment also stated the resident was a candidate for hearing aids and recommended medical consultant clearance for hearing aid use, but the DON stated there was no documentation that the physician had been notified of these hearing recommendations.
Failure to Provide Scheduled Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for dependent residents. During an interview, Resident #63 stated that he/she had to wait a long time to get cleaned up. Review of shower documentation showed that Resident #63 was scheduled for showers on Mondays and Thursdays, but on 2/3/26 and 2/19/26 the shower days were coded as not applicable. The resident had been out of the facility on several days in the middle of February, but on the days the resident was in the facility, shower days were open for documentation. The acting DON reviewed the records and stated she could not find additional documentation showing that a shower was offered or provided on those two scheduled shower days. Resident #9 stated during interview that he/she was only offered a shower once a week even though the schedule was for Mondays and Thursdays. Shower documentation for February 2026 showed showers on 2/6/26, 2/9/26, and 2/16/26, with a tub bath on 2/19/26, and no refusals were documented. The resident was assessed on the MDS as needing partial to moderate assistance with showering. The Unit Manager confirmed that Resident #9 was scheduled to receive showers twice a week and did not recall any refusals, and also confirmed that the documentation showed the resident received only one shower per week even though two were scheduled.
Failure to Administer Insulin and Notify Provider for Elevated Blood Glucose
Penalty
Summary
The facility failed to identify and provide appropriate interventions and notifications for abnormal blood glucose management for two residents receiving insulin. For one resident, the record showed an order for Humalog 6 units subcutaneously with meals to cover carbohydrate intake, but on 2/24/26 the dose was coded as 14 and not given with the meal. The resident’s blood glucose was 89 at 6:30 AM and rose to 400 at 11:30 AM after the insulin was not administered with the meal. The record also showed blood glucose values of 411 at 11:30 AM and 449 at 8:00 PM on 2/25/26. A correction-scale order was later added stating to give 8 units of Humalog for blood glucose between 351 and 400, with the correction dose to be given with meals along with the 6-unit carbohydrate coverage, and to call the provider if blood glucose was greater than 400. Both administrations were labeled 9 with a progress note reference, but there was no note showing the response, and the acting DON stated there was no documentation that the provider was called for the two blood glucose readings over 400. For another resident, the MAR showed bedtime blood glucose readings as high as 410 mg/dL during 23 documented readings in February 2026. Review of prior blood glucose readings from November 2025 through January 2026 showed values ranging from 100 mg/dL to 328 mg/dL. The medical record did not contain documentation that the physician had been notified of blood glucose readings at or above 400 mg/dL. During interview, the DON stated nursing staff were expected to notify the physician when abnormal blood glucose levels were identified and acknowledged that readings at or above 400 mg/dL should have been reported, but later confirmed there was no documentation that the physician had been notified of the elevated readings.
Failure to Arrange Hearing Services for a Resident
Penalty
Summary
The facility failed to ensure that Resident #48 received services to address hearing needs. During an interview, the resident reported having requested a hearing screening some time ago but stated the request had not been addressed and that they were still waiting for a hearing test. A review of the resident’s medical record did not reveal documentation of a hearing screening appointment or consultation. The DON stated the facility used an outside consultant service for hearing, vision, and dental needs, and later acknowledged that the facility failed to submit the required audiology documentation to the hearing consultant in July 2025, resulting in the resident not receiving the hearing screen.
Hand Splint Orders Were Conflicting and Not Reflected in Care
Penalty
Summary
Facility staff failed to clarify appropriate care measures to prevent complications from a hand contracture for one resident who had a contracted left hand. On 2/24/26 and again on 2/26/26, the resident was observed resting in bed with the left hand contracted, and the hand splint was noted on the bedside table rather than on the resident. The report states that failure to protect the palm of a contracted hand can result in injury from the pressure of fingers or fingernails pressing into the palm. The resident had two left-hand splint orders in the record: one written on 11/4/25 for a palm guard splint to the left hand at all times except bathing and hygiene, and another written on 11/5/25 for a left palm protector 6-8 hours or as long as tolerated every day. The February and March TARs documented both orders as completed, even though the care plan noted the resident refused to wear a palm guard at times and the TARs did not capture that behavior. OT discharge notes dated 1/23/26 recommended a palm guard on the affected hand at all times, 27/7 care. On 3/3/26, the resident was again observed with the splint not on but on the floor next to the bed, and the acting DON stated the resident should not have two conflicting orders and that the most recent recommendation should be active; she also stated the TAR should reflect the care provided.
Improper Handling of Tube Feeding and Water Hydration Bags
Penalty
Summary
Appropriate care was not provided for a resident who required enteral nutrition. During observation, a bag of water hanging beside the resident’s tube feeding bottle was found labeled H2O with a date of 2/23/26 and time of 2 PM, while the tube feeding bottle was dated 2/25/26 at 11 PM. On a later observation, the resident’s tube feeding bag was dated 2/27/26, but the water bag still appeared to have the same label as the prior day, with the date altered by writing over it rather than replacing the bag. During interview, the acting DON stated that both the tube feeding and water hydration bags should be changed every 24 hours and acknowledged that relabeling the water bag was not accepted practice. The facility policy titled Enteral Feeding - Safety Precautions stated that administration sets are to be changed every 24 hours and as needed, and that tubing is to be labeled with the date and time of change.
Missing Night Shift Supervisor and Delayed Medication Administration
Penalty
Summary
The facility failed to have a designated nurse supervisor/charge nurse on the night shift. During an early morning observation, an LPN was asked who the night shift supervisor was and stated she was not sure, then another LPN stated she did not believe there was a nighttime supervisor last night and that the day time supervisor would be in shortly. When the acting DON was interviewed, she later identified one LPN as the nighttime supervisor and stated that LPN had been given supervisor materials, but the staffing sheet reviewed with the acting DON did not list a designated supervisor for the night shift, even though other days did list one. The facility also failed to have sufficient staff to dispense medications in a timely manner. During medication administration observation, one LPN pushed the medication cart down the hall but stated she normally would not be administering medications because a CMA usually did that, and the CMA was scheduled off. The LPN had to stop to provide nursing care to a resident, respond to a call light, and carry a laboratory specimen before she could begin medication administration. She did not start administering medications until 31 minutes after first bringing the cart down the hallway, and some medications scheduled for 8:00 AM were administered at 9:40 AM, 1 hour and 40 minutes late. During the observation, the LPN was repeatedly interrupted by resident needs while trying to administer medications.
Failure to Post Required Staffing Information
Penalty
Summary
The facility failed to post all required nurse staffing information on a daily basis. On 3/2/26 at 6:06 AM, the surveyor observed the Plexiglas tray at the front desk empty, even though staffing hours had been posted there on previous survey days. At 6:09 AM, an LPN was asked who the night shift supervisor was and stated she was not sure, then went to ask another LPN. At 6:11 AM, the surveyor observed the whiteboard at the nurses' station, where assignments had been posted on other survey days, and found it blank. The LPN stated the board had been wiped clean so the unit clerk could put up the new assignment, and also stated the unit manager had not arrived yet. When asked about the night shift supervisor, the LPN stated she did not believe there was a nighttime supervisor last night and that the daytime supervisor would be in shortly. At 7:54 AM, the acting DON confirmed that the posted staffing should have been available.
Medication Administration Error
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to administer medications according to procedures that ensure accurate dispensing for Resident #82. During observation, an LPN prepared Resident #82's medications and placed only one 150 mg bupropion hydrochloride extended-release tablet into the medication cup with the resident's other medications, then administered the medications to the resident. Review of the medication order showed that Resident #82 was ordered 3 tablets of bupropion hydrochloride extended-release oral tablet 150 mg once daily. During interview, the LPN stated she did not realize she had given only one tablet instead of three and said she would need to administer two additional tablets to give the ordered dose.
Duplicate Vitamin D Order Not Clarified Promptly
Penalty
Summary
The facility failed to adequately monitor a resident’s drug regimen, resulting in an unnecessary duplicate medication order for Cholecalciferol (Vitamin D) 1000 units for one resident. During medication preparation and administration, an LPN pulled and administered one Vitamin D tablet, but the resident’s medication orders showed two separate orders for the same 1000-unit tablet, creating the appearance that two doses were to be given. The MAR also had two areas to document the medication, and both appeared marked as given even though only one dose was observed administered. During interview, the LPN stated she had only given one dose because she noticed the duplicate order, but she had not yet contacted the provider to remove it. The acting DON later stated the physician had entered the order once but checked two routes in error, causing the order to appear twice on the MAR. The duplicate order had been present since February 13 and had not been clarified until after surveyor review, and the acting DON agreed the delay in addressing it was concerning.
Unsecured medication cart with resident medications and personal items
Penalty
Summary
The facility failed to properly store a resident's medication when a medication cart in the 100's hallway was left accessible and unsecured. During observation, a surveyor saw CMA #4 walking between two medication carts, with one cart turned front side against the wall between room [ROOM NUMBER] and 111. When the surveyor later checked the cart, the side drawer could be opened and contained colestipol oral suspension, lactulose, and lidocaine patches. The top drawer contained multiple bottles of floor stock medication, the second drawer contained bubble packs of resident medications, and the third drawer contained a personal water bottle along with additional medications. CMA #4 stated she was responsible for the medication cart and confirmed she was supposed to lock it before leaving it unattended. She also stated she was not supposed to keep personal items in the cart and had turned it toward the wall because she was returning shortly and had to share keys with the other nurse. The acting DON stated that staff should have their own keys, medication carts should be locked when unattended, and personal items should not be stored in the med cart. The facility policy reviewed by the surveyor stated that medication carts containing drugs and biologicals shall be locked when not in use and shall not be left unattended if open or otherwise potentially available to others.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure that residents who required dental services on a routine or emergent basis received necessary or recommended dental care in a timely manner. For one resident, the record showed repeated documentation of tooth pain over several weeks, including notes stating that a dental consultation was pending and recommendations to arrange a dental evaluation for suspected odontogenic pain. The resident had orders for Orajel for tooth pain and later had a dental appointment noted for early March, but the record reviewed by the surveyor showed multiple provider notes documenting ongoing dental pain before any appointment had been arranged. The acting DON stated that the family member made the dental appointment after being informed of the pain during a care meeting. For a second resident, the surveyor observed that the resident stated a need for dentures and reported that the facility had not followed up. The resident’s MDS assessments from 10/16/24 and 10/18/25 both indicated obvious or likely cavity or broken natural teeth, but the annual MDS from admission did not show dental concerns. When the surveyor requested documentation of dental care provided in response to those assessments, the Administrator reported that no follow-up dental care could be found after the MDS assessments were made.
Meals Not Served According to Menu and Resident Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to a predetermined menu and their preferences. During the recertification survey, meal observations and resident interviews showed that several residents did not receive the foods listed on their meal tickets. One resident stated that breakfast was supposed to be sausage gravy on biscuits but received scrambled eggs with dry toast instead, while the meal ticket listed sausage gravy with biscuits. Another resident stated that the tray did not match what was supposed to be served and that cottage cheese, which was supposed to be provided with all meals, was never received; the tray instead contained boiled eggs and toast. For another resident, the breakfast tray did not include the alternative breakfast meats listed on the meal ticket, and the resident stated that items received were not listed on the ticket and that foods listed in the dislikes section were being served. A GNA stated that the kitchen does not update the tickets when foods are unavailable and that residents often get foods listed in their dislikes. The same resident later received oatmeal, which was listed in the dislikes, and still did not receive cottage cheese, and the GNA stated the kitchen did not have an alternative breakfast meat available that day.
Cold Food Served With Inconsistent Reheating Practices
Penalty
Summary
The facility failed to serve food at residents’ preferred temperature, with the concern identified for 2 of 8 residents interviewed about palatable food during the recertification survey. Two residents stated that the facility food was served cold and that staff were too busy to heat it up. During a meal observation, one resident stated, “My food is ice cold and the facility won’t heat my food,” and refused to call for assistance when encouraged. Staff responses about reheating food were inconsistent. A GNA stated that staff were not allowed to heat resident food, while the acting DON stated staff were supposed to return food to the kitchen for reheating. Another GNA stated that she heated food in the microwave in the break room because there was nowhere else to do it. During tray pass observation, the surveyor noted the tray cart door was left open after a tray was removed. The Food Service Director stated there were frequent complaints about cold food, that staff were notified when trays were delivered to the floor, and that one side of the plate warmer was broken. The RDCO stated he was not sure what the reheating policy was and would follow up on it.
Missing Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices for meals to Resident #14, despite a physician order dated 10/28/2025 directing the resident to use a weighted spoon and fork during meals and a care plan dated 10/29/25 listing divided plate for meals, a sippy cup, and a built up spoon. During observation on 02/26/2026, the resident was seen eating breakfast with a fork while the hands visibly shook and food fell from the fork as the resident tried to eat. The resident was observed again later the same day eating breakfast with a fork, with the same visible shaking and food falling from the fork. When asked whether the facility provided assistive utensils, the resident shook their head no. Staff interviews indicated that if assistive devices were needed and not found on the tray, staff would go to the kitchen to try to find them, and the Food Service Director stated the meal ticket indicates the need and staff puts the devices on the tray; the surveyor then observed staff getting assistive devices from the dish room. The Administrator and DON acknowledged the concern about the missing assistive devices during interview.
Unsafe Food Storage and Labeling Practices
Penalty
Summary
Sanitary and safe food handling practices were not followed in the kitchen, refrigerator, freezer, and storage areas during the recertification survey. In the refrigerator, 3 sandwiches were found on a shelf dated 2/20/24 and were discarded by the Food Service Director. Spices in the cooking area were observed without labels or dates, and the Food Service Director stated staff should label them with the date opened. In the walk-in freezer, surveyors found an unlabeled bag of green beans and a box of hash browns with a large ice formation on top that was almost covering the box, with icicles hanging from the compressor above it; the Food Service Director stated the food would be discarded and a repair requested. In the walk-in refrigerator, ham dated 2/16/26 with a use-by date of 3/2/26 was observed, and the Food Service Director stated it should be discarded after 7 days. The Administrator acknowledged the kitchen concerns and stated the compressor repairs would be addressed that day.
Incomplete PASARR Documentation
Penalty
Summary
The facility failed to ensure that a resident’s medical record document was accurately completed for Resident #10, who was reviewed for PASARR. Review of the record showed a PASARR document dated 2/11/25 that indicated the resident needed a level II screening. However, the medical record did not contain documentation showing that a level II PASARR was completed or that a level II screening was determined to not be required. During interviews, the Director of Social Services stated that if a level I PASARR indicated the need for a level II screen, the facility would contact AERS, which would determine whether a level II screen was needed based on the level I information. On follow-up, the Director of Social Services was unable to find any indication that AERS had been informed about the level I screen or whether a level II was needed. He also stated that the level I screen had been filled out incorrectly on section C question 2 and that a new one would have to be completed and resubmitted. The DON reviewed the concern and indicated understanding.
Improper Storage of Clean Linen on Hallway Carts
Penalty
Summary
The facility failed to ensure linens were stored to maintain infection prevention, as shown by observations of linen carts on four hallways during the annual survey. On the 500 hallway, a linen cart had a visibly dirty seat cushion, a wheelchair detachable leg/foot rest, a reusable bed pad, trash bags, and a brief on the bottom shelf, and the same items remained on the cart during a later observation. The DON stated that linen carts on the hallways should only contain linen to maintain infection prevention. During a dual observation of the 100, 200, and 300 hallway linen carts, the 100 hallway cart contained an opened size large gloves box, cleanser, lotion, approximately 4 briefs, trash bags, plastic cups, two packs of adult wash cloths, a packet of ointment, and a sheet of paper. The 300 hallway cart had 4 basins containing items such as plastic cups with lids and straws, zinc oxide paste, briefs, and toothbrushes. The 200 hallway cart had briefs on the top shelf. On the 300 hallway, the clean linen cart was also observed with the front cover up, exposing the clean linen inside; the DON stated the cover should be down unless linen is being removed, and a GNA later stated the cover should be down and covering the clean linen at all times.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to keep kitchen equipment in safe, operating condition, including the walk-in freezer, plate warmer, and hot water heater. During a kitchen tour, the surveyor observed a large ice formation on top of a box of hash browns in the walk-in freezer, with icicles hanging from the compressor above the box. The Food Service Director stated that a repair request would be submitted. Later, the Maintenance Director stated the freezer compressor needed charging and might be serviced that day, and the Administrator stated they were working on the compressor. On a later observation, the walk-in freezer still showed small drips on the compressor, and the Food Service Director stated there was a plan to have maintenance evaluate the freezer. The surveyor also observed that one side of the plate warmer was broken, and the Food Service Director stated this was contributing to complaints about cold food and that a work order had been placed. In addition, during an attempt to observe dishwashing, Dietary Aid #39 stated the hot water heater was broken and dishes could not be safely washed. The Maintenance Director stated the process would not work until hot water returned, and the Administrator stated the facility was using paper products and planned to wash dishes once hot water returned. A later dish machine observation showed wash temperatures at 142 and rinse temperatures at 186, and the Administrator stated the facility had called for emergency repairs.
Call System at Nurses' Station #3 Was Not Functioning Properly
Penalty
Summary
The facility failed to ensure that the resident call system was functioning properly at nurses' station #3, which was observed continuously beeping every three seconds even though no resident call lights were activated and no room numbers were appearing on the screen. During the survey, RN #6 stated the issue had been present for a while and that maintenance had looked at it but was unable to fix it. The Maintenance Director later confirmed that he was unaware the call system at nurses' station #3 was not working properly, observed the same continuous beeping during the survey, and stated that the other nurses' stations did not have this issue. The Nursing Home Administrator stated she was aware of the problem and that maintenance was working on fixing it.
Missing Annual Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to ensure staff received training on abuse, neglect, and exploitation for 2 of 6 employee files reviewed during the annual survey. During an interview, the DON stated that nursing skills competencies are verified at orientation and reassessed annually, and that the facility uses Relias for required monthly and annual training. Review of the facility assessment approved in January 2026 showed staff training requirements that included abuse, neglect and exploitation, infection control, dementia management, quality assurance and performance improvement, and compliance & ethics. However, review of the employee files for GNA #36 and LPN #38 did not show evidence of abuse training, and the DON later acknowledged that the required 2025 annual abuse, neglect, and exploitation training for those two staff members was not completed.
Missing QAPI Training for Staff
Penalty
Summary
The facility failed to ensure staff received training on Quality Assurance and Performance Improvement (QAPI). During the annual survey, administrative record review and staff interviews showed that the facility assessment approved in January 2026 identified staff training requirements that included QAPI, along with abuse, neglect and exploitation, infection control, dementia management, and compliance and ethics. The Director of Nursing stated that nursing skills competencies are verified at orientation and reassessed annually, and that the facility uses Relias for required monthly and annual training. However, review of the employee files for GNA #36, GNA #37, and LPN #38 showed no evidence of QAPI training, and the DON acknowledged that the required annual training for these staff members was not completed in 2025.
Missing Infection Control Training for Staff
Penalty
Summary
The facility failed to ensure staff received infection control training as part of its infection prevention and control program, which includes mandatory training with written standards, policies, and procedures. During the annual survey, the Director of Nursing reported that nursing skills competencies are verified at orientation and reassessed annually, and that the facility uses Relias for required monthly and annual training. Review of the facility assessment approved in January 2026 identified staff training requirements including infection control. However, review of the employee files for GNA #36, GNA #37, and LPN #38 showed no evidence of infection control training, and the DON later acknowledged that the required annual infection control training for these three staff members was not completed in 2025.
Missing Compliance and Ethics Training for Staff
Penalty
Summary
Failure to ensure staff received compliance and ethics training was identified during the annual survey after administrative record review and staff interview. The DON stated that nursing skills competencies are verified at orientation and reassessed annually, and that the facility uses Relias for required monthly and annual training. Review of the facility assessment approved in January 2026 showed that staff training requirements included abuse, neglect and exploitation, infection control, dementia management, QAPI, and compliance and ethics. However, review of the employee files for GNA #36, GNA #37, and LPN #38 showed no evidence of compliance and ethics training. When the DON was asked about the missing 2025 compliance and ethics training for these three employees, the DON acknowledged that the required annual training had not been completed in 2025.
Inaccurate MDS Coding of Resident Falls
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents with documented falls. For one resident, medical record review showed two falls within the assessment look-back period: one fall without injury and a subsequent fall resulting in a scalp laceration requiring emergency room evaluation and placement of two staples. However, the annual MDS with an assessment reference date of 11/20/25 captured only one fall without injury and did not include the fall with injury. For another resident, records documented two separate falls, both described in change in condition notes as the resident being found on the floor near the bed with no injuries noted, but the MDS with an assessment reference date of 11/21/25 captured only one fall without injury. Additional record reviews identified further inaccuracies in MDS fall coding. One resident had a documented fall where the resident was found kneeling on the floor after attempting to transfer from bed to wheelchair, with no injury noted, yet the MDS with an assessment reference date of 11/18/25 documented no falls. Another resident experienced a fall reported by a housekeeper, where the resident was standing at the end of the bed, began coughing, and then sat on the floor, with no injuries noted; the MDS with an assessment reference date of 1/6/26 also documented no falls for this resident. In each of these cases, the MDS Coordinator confirmed during interview that the falls had not been accurately captured on the MDS assessments, and the Nursing Home Administrator was informed of the concern.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
Surveyor observation identified a failure to maintain a safe, clean, comfortable, and homelike environment in one resident room. On 2/3/26 at approximately 10:15 AM, the surveyor entered room [ROOM NUMBER] B, where Resident #1 resides, and observed trash scattered on the floor, including wrappers, Kleenex, a hair brush, and food. Leftover food and crumbs were present on the bedside tables for both Resident #1 and the roommate, and there was stuck-on food on the cushion of the wheelchair. The floor mat was dirty, and the corners of the room were dusty and dirty. These conditions were shown to the Charge Nurse (staff #7) and the DON (staff #2); staff #7 stated that Resident #1 is a messy eater and gets food everywhere, but the roommate’s side of the room was also observed to be just as dirty. The Administrator was made aware of these findings. This deficiency reflects the facility’s failure to adequately clean the resident room, including sweeping and mopping the floor and maintaining clean surfaces and equipment, for 1 of 1 residents and rooms reviewed in this context.
Failure to Implement Ordered Pressure Ulcer Treatment
Penalty
Summary
Facility staff failed to provide ordered treatment and services to prevent and heal a pressure ulcer for one resident. The resident was admitted in 2024 with diagnoses including adult failure to thrive, characterized by unintentional weight loss, decreased appetite, poor nutrition, and physical inactivity. On 3/18/25, a weekly skin observation note documented a new skin condition measuring 4 cm by 1 cm on the resident, described as pink in color with no drainage, which was cleansed with wound cleanser and dressed. On 3/20/25, a Wound Doctor assessed this area as a Stage III pressure ulcer on the left buttock and ordered a daily Calcium Alginate dressing. On 3/27/25, the Wound Doctor discontinued the Calcium Alginate dressing and ordered zinc ointment to be applied every shift. Review of the March 2025 Treatment Administration Record showed that facility staff did not implement the Wound Doctor’s 3/20/25 order and continued using wound cleanser instead of changing to the ordered Calcium Alginate dressing from 3/20/25 through 3/27/25. In an interview on 2/4/26, the Regional Director of Clinical Operations confirmed these findings, verifying that the ordered pressure ulcer treatment was not provided during that period.
Failure to Implement Dietitian Recommendations and Follow Up on Weight Loss Evaluation
Penalty
Summary
Facility staff failed to implement the dietitian’s recommendations and to follow up on a physician-ordered GI consult for residents experiencing weight loss. One resident with dementia, adult failure to thrive, mild protein-calorie malnutrition, and other comorbidities continued to lose weight despite supplementation and meal assistance. The dietitian assessed this resident and documented that a GI telehealth consult had been ordered due to ongoing weight loss and a history of being underweight. However, there were no GI consult notes in the electronic or paper medical record, and the Acting DON confirmed that staff did not have the results of the consult, leaving the facility unable to determine if there were any recommendations related to the resident’s weight loss. The dietitian also ordered weekly weights times four for this same resident, but the weight for one of the scheduled weeks was not obtained, as confirmed by the Regional Director of Clinical Operations. A second resident, admitted with a diagnosis including malnutrition, was assessed by the dietitian for weight loss, and the dietitian again recommended weekly weights times four. Staff obtained only two weights and then stopped, and the dietitian did not see this resident again after the initial assessment. These missed weights and lack of follow-up on the GI consult occurred for two of three residents reviewed for weight loss during a complaint survey.
Failure to Obtain Timely CT Imaging After Abnormal Chest X-Ray
Penalty
Summary
Facility staff failed to obtain a timely diagnostic CT scan as recommended and ordered for a resident with a history of goiter. The resident was admitted in 2024 with diagnoses including goiter and later had a chest X-ray on 3/3/25 to rule out pneumonia. The X-ray report noted nonspecific superior mediastinal widening with overall findings worse compared to a prior study from 4/22/2024 and specifically recommended a CT scan. Despite this recommendation, a physician order for the CT scan was not placed until 3/28/25. That order was updated on 4/3/25 to include a scheduled CT date of 4/8/25. On 4/7/25, the CT scan order was discontinued because the imaging provider would not take the resident on a stretcher, and no alternative arrangements were documented in the record at that time. The resident was hospitalized from 4/15 to 4/18/25, and the hospital discharge summary again referenced imaging that showed moderate left paratracheal soft tissue density deviating the trachea to the right, compatible with probable substernal thyroid, and recommended correlation with a chest CT as an outpatient. The chest CT was not ordered or obtained until the resident was sent to the hospital on 6/9/25. The Regional Director of Clinical Operations confirmed that facility staff failed to follow up and obtain the CT scan from 3/3/25 until 6/9/25.
Failure to Clearly Post Location of Survey Results Book
Penalty
Summary
The facility failed to post a notice indicating where the results of the most recent surveys, certifications, and complaint investigations were located, limiting residents’ and visitors’ ability to easily view the survey book. During a complaint survey, a surveyor observed that there were no signs in the lobby identifying the location of the survey book and had to ask the receptionist, who stated the book was kept in a drawer of a black table across the lobby from the Nursing Home Administrator’s (NHA) office. The table had plants on top and two drawers, and there was no signage on or near the table, on the wall, or elsewhere in the lobby to direct individuals to the survey book. Later, a survey sign was found on a wall in a nursing unit stating that the state survey book was located in the front lobby, but it did not specify that the book was kept in a drawer. In an interview, the NHA explained that she kept the survey binder in the drawer because a resident had previously torn the book apart. The Regional Director of Clinical Operations reported that they usually had a sign posted but could not locate it, and the receptionist did not know where the sign was, confirming that no clear notice of the survey book’s location was available at the time of the survey.
Failure to Maintain Effective Grievance System and Documentation
Penalty
Summary
The facility failed to maintain an effective grievance system as required, as evidenced by missing and incomplete grievance documentation over a six-month period. Specifically, grievance forms were unavailable for four out of six months reviewed, and the forms that were available for one month lacked essential information such as actions taken to investigate grievances, summaries of conclusions, dates of resolution, corrective actions implemented, and documentation of how the disposition was communicated to the complainant. This deficiency was identified during a complaint survey following allegations from two residents, one regarding missing personal belongings and another concerning unreturned calls after voicing concerns. Interviews with the DON and Administrator confirmed that the facility's process involves documenting concerns on forms and distributing them to the appropriate departments, with an expectation that grievances are resolved within seven days and all details are documented. However, both the DON and Administrator acknowledged that the grievance forms for the reviewed period were either missing or not fully documented, and the facility was unable to provide forms for four of the six months requested. This lack of documentation and incomplete records demonstrated the facility's failure to establish and maintain an effective grievance policy and process.
Failure to Provide Adequate Linen and Hygiene Supplies for Resident Care
Penalty
Summary
The facility failed to provide adequate quality of care services by not ensuring the availability of clean towels, washcloths, and other hygiene materials for residents. Multiple complaint intakes revealed that residents were left in soiled adult briefs for extended periods and were not bathed during their initial days at the facility due to a lack of clean linens. Family members had to purchase towels and washcloths themselves to provide basic care. Staff interviews confirmed that linen shortages were a frequent issue, with aides often unable to find necessary supplies and sometimes being instructed to use bed sheets or pillowcases as substitutes. Observations of linen carts on multiple units showed a lack of washcloths and only a few towels available. Further interviews with staff, including a Geriatric Nursing Assistant and a laundry aide, indicated that the facility did not have enough linen to meet residents' needs, and the process for recycling and distributing linens was disorganized. Staff reported that linens were sometimes hidden in residents' closets or discarded when heavily soiled, exacerbating the shortage. The Environmental Services Director and the Administrator acknowledged ongoing complaints from residents, staff, and families regarding linen shortages, and confirmed that the issue persisted, directly impacting the ability to provide timely and appropriate care.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility failed to provide an environment that promotes resident respect and dignity, as evidenced by a resident ambulating down a hallway wearing only a hospital gown that was hanging off one shoulder and exposing the resident's back. During interviews, a Geriatric Nursing Assistant stated that many residents were seen in hospital gowns because they did not have clothes. Observation of the resident's closet revealed only one sweatshirt available. The Registered Nurse confirmed the resident had been exposed while walking in the hallway, and the Assistant Director of Nursing acknowledged that such exposure would be considered a dignity issue.
Failure to Honor Resident's Shower Preference
Penalty
Summary
A resident with Parkinson's Disease, who is dependent on staff for activities of daily living (ADLs), expressed a clear preference for receiving showers rather than bed baths. Despite a physician's order specifying a weekly shower schedule and the resident's stated preference, the resident reported not having received a shower in over two years. The resident also noted that the shower room on the unit was not in use and was being used to store wheelchairs. Medical record review confirmed that the resident's care plan did not include the preference for showers and that documentation for the month showed only bed/towel baths were provided, with no record of showers. Interviews with facility leadership, including the DON, confirmed that resident preferences should be honored and reflected in the care plan, but this was not done in this case.
Failure to Maintain Odor-Free and Homelike Environment
Penalty
Summary
Facility staff failed to ensure a safe, clean, and homelike environment by not maintaining the facility free from odors. During tours conducted on multiple days, a surveyor observed persistent smells of urine and foul odors, possibly body odor, in specific areas of two out of four nursing units. These odors were noted at the far end of the 300 unit on several occasions and halfway down the hall farthest from the nurses station in the 500 unit. The findings were based on both anonymous and family complaints, as well as direct observations by the surveyor during the complaint survey. No specific information about the medical history or condition of individual residents was provided in the report. The deficiency was discussed with facility administration during the exit conference.
Failure to Conduct Thorough Investigations of Abuse Allegation and Serious Injury
Penalty
Summary
The facility failed to conduct thorough investigations into two separate incidents involving residents. In the first case, a resident was hospitalized with a rib fracture and pneumothorax after a fall, and reported to hospital staff that they had been pushed by an unknown person, constituting an abuse allegation. Although the facility initiated an abuse investigation upon the resident's return, there was no documentation of witness statements or interviews with staff and other residents. The DON was unable to provide these documents, stating that the investigation had been handled by former staff and that the necessary records could not be located. In the second incident, another resident complained of leg pain and swelling upon arrival at a dialysis center, stating they had been dropped at the facility. The dialysis nurse communicated this to the facility and documented the conversation, but the corresponding communication flow sheet later returned to the facility was missing the nurse's written notes and signature. The facility's incident report indicated the resident was injured during transport due to not being strapped in, resulting in a femur fracture. Despite this, there were no statements from the van driver, escort, resident, facility nurse, or geriatric nursing assistants involved in the incident, and the facility could not produce documentation of a thorough investigation. Both incidents demonstrate a lack of comprehensive documentation and investigative follow-through, as required when responding to allegations of abuse or serious injury. The absence of witness statements, staff interviews, and relevant communication records contributed to the facility's failure to appropriately respond to and investigate these significant events.
Failure to Develop Individualized Mobility Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing impaired mobility for a resident with a history of left-sided paralysis and weakness. During a complaint survey, it was found that the resident was dependent on staff for activities of daily living, including mobility and transfers. Despite this, there was no documented evidence that a resident-specific care plan was created to address the resident's mobility needs or to outline the interventions implemented to assist with mobility. The deficiency was identified through a review of medical records and care plans, as well as interviews with facility staff. The Assistant Director of Nursing confirmed that the care plan did not adequately address the resident's mobility needs after reviewing the documentation. The lack of a comprehensive, individualized care plan for mobility was observed in one of four residents reviewed for mobility needs during the survey.
Failure to Provide Timely Incontinence Care and Adequate Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide timely and professional incontinence care, as well as adequate bathing for dependent residents. In one instance, a resident who returned from therapy after a bowel movement waited 57 minutes before receiving incontinence care, despite multiple staff being informed of the need. Staff interviews revealed that coverage during breaks was inconsistent, leading to extended wait times for residents requiring assistance. Additionally, documentation showed that another resident was not bathed according to their scheduled shower days during their short stay, and a review of another dependent resident's records indicated they received only one shower in a month without any documentation of refusal. Staff confirmed that only one of two shower rooms in a unit was functional, with the other out of order for several months, resulting in only four working showers for 130 residents. Furthermore, a resident was left in a hallway from 4 AM to 12 Noon after being moved out of bed for linen changes following an incontinence episode. Interviews with family and anonymous sources confirmed that the resident called out for help throughout the night and was left unattended in the hallway for several hours. These findings were based on observations, record reviews, and staff and family interviews, demonstrating a pattern of delayed and inadequate care for residents dependent on staff for activities of daily living.
Failure to Conduct Thorough Accident Investigation
Penalty
Summary
Facility staff failed to conduct a thorough investigation following an accident involving a resident with severe intellectual disabilities who was found on the floor of their room with a hematoma and a laceration over the left eyebrow, accompanied by significant bleeding. The resident reported getting up to walk to the bathroom and falling, resulting in head trauma. Staff provided immediate care, including applying ice and a pressure dressing, and the resident was sent to the hospital. Upon review, it was found that the facility's assessment of the incident did not include interviews with staff or the resident's roommate, which limited the ability to determine the root cause of the fall. The assessment only noted the resident's alertness, periods of forgetfulness, impaired memory, and gait imbalance, and concluded that ambulating without assistance was a predisposing factor. The lack of comprehensive investigation denied staff the opportunity to fully evaluate the causes of this and potential future accidents.
Failure to Serve Cold Foods at Safe Temperatures
Penalty
Summary
Facility staff failed to ensure that food was served in a palatable manner, as observed during a test tray evaluation. On 10/9/25 at 8:30 AM, a test tray was provided to the survey team, and while the scrambled eggs and bacon were at a palatable temperature, the cream cheese, milk, and apple juice were all served above the 41-degree Fahrenheit limit for cold foods, with temperatures recorded at 53.9 F, 52.8 F, and 49.6 F respectively. This deficiency was identified for one out of two test trays sampled and was communicated to the facility administrative team during the exit conference.
Failure to Verify Meal Information Before Service
Penalty
Summary
The facility failed to properly verify essential meal information prior to serving food to a resident. During a meal service observation, a Geriatric Nursing Assistant served a meal tray to a resident without a meal ticket, which is required to confirm the resident's name, room number, diet type, food texture, liquid consistency, and allergies. The GNA acknowledged that the tray should not have been served without this verification. Interviews with staff confirmed that the standard procedure is to return any meal tray lacking a meal ticket to the kitchen, and the Director of Nursing stated that staff are expected to verify all meal tickets before serving trays to residents.
Incomplete Medical Records and Missing Dialysis Communication Documentation
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident who experienced a leg injury during transport to a dialysis center. The incident began when the resident, who had a history of advanced osteoporosis and a prior fracture in the same leg, complained of leg pain and swelling upon arrival at the dialysis center. The dialysis nurse documented the resident's complaints, vital signs, and communication with the facility nurse on a flow sheet, which was sent back to the facility. However, upon review, the communication flow sheet for the relevant date was missing the dialysis nurse's written notes and signature. The facility's records included an incident report and subsequent medical interventions, such as Tylenol administration, notification of the CRNP, diagnostic imaging, and pain management, but lacked the original documentation from the dialysis center. Interviews with facility staff, the dialysis nurse, and the Director of Nursing revealed inconsistencies and gaps in the documentation process. The Director of Nursing stated that the previous Administrator may have taken investigation records with them, and the dialysis communication flow sheet for the incident date was found to be incomplete. Staff interviewed were unaware of the missing documentation, and the communication logs provided did not contain the dialysis nurse's original notes. This failure to safeguard and maintain complete resident medical records, specifically the communication flow sheets with the dialysis center, constituted the identified deficiency.
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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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