Ridgeway Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Catonsville, Maryland.
- Location
- 5743 Edmondson Avenue, Catonsville, Maryland 21228
- CMS Provider Number
- 215227
- Inspections on file
- 18
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Ridgeway Rehab Center during CMS and state inspections, most recent first.
Advance directive and incapacity documentation were incomplete for multiple residents. A resident who was alert and oriented on admission had no documented advance directive status in the social work note or baseline care plan, and two residents had certificates of incapacity that were missing a diagnosis or clinical reason on at least one form. The DON and Regional DON reviewed the records and confirmed the documentation gaps.
Facility staff failed to complete BLCPs within the required timeframe and did not document that the BLCP summary and current med list were given to the resident or representative. For some residents, care plans were created or discussed out of sequence with the MDS process, and the record lacked evidence that copies of the care plans were provided to the resident or family.
Care plan meetings were not consistently held or documented with quarterly revisions, and residents and/or their representatives were not reliably invited. Survey review found missed or mismatched care plan meetings for multiple residents, including cases where care plans were written before the care plan meeting, meetings were absent for some assessment periods, and one resident reported never being invited to a care plan meeting since admission. Staff acknowledged missing documentation and that the SW process was being monitored more closely.
A resident reported that meal portions were too small and that requests for larger portions were refused. The resident was also served mashed potatoes instead of the roasted red skin potatoes listed on the meal slip, and did not know of the change until the tray arrived. The dietician said the resident was ordered double portions, while the resident stated that no one asked whether he/she wanted to lose weight despite a large weight loss since admission and a high BMI.
A resident room had no chairs, leaving visitors and residents without a place to sit, and another room had a bedside table with chipped edges. Survey staff also observed dangling plastic edging from a bed footboard. The Administrator confirmed the issues during the tour.
Failure to Promptly Address Resident Grievance: A resident’s family reported safety concerns with a roommate, including intimidating behavior and repeated boundary issues, and requested a room change. RN documentation showed the request was noted after a conflict was reported, but no further action was taken at that time. The room change occurred later, and the DON could provide only one unrelated grievance form for the resident.
A resident with LBD, Parkinson's disease, anxiety, and depression was prescribed clozapine twice daily and clonazepam at bedtime without adequate documented clinical indication. The PNP stated clonazepam should be used for schizophrenia or anxiety, but review of the attending provider's documentation and PMH showed no dx or clinical documentation of schizophrenia to support the antipsychotic and benzodiazepine regimen.
A resident with LBD, Parkinson’s disease, anxiety, and depression had an MDS that only coded dementia and Parkinson’s disease, leaving Section I psychiatric/mood disorders incomplete. The MDS Coordinator confirmed the missed diagnoses and stated that anxiety and depression were not included from provider records, and the DON validated the finding.
Failure to provide needed grooming and personal hygiene assistance: A resident with an ADL self-care deficit was observed in bed with outgrown, dirty fingernails and toenails, unshaven facial hair with food particles, and stained clothing/gown. On a later observation, the resident was still in bed wearing only a diaper, with nails still not trimmed and stained underneath. The care plan included assistance with grooming, keeping nails short, and daily body checks, and both the GNA and ADON acknowledged the resident appeared unkept.
Failure to follow a consulting MD’s recommendation and to administer ordered meds as prescribed. One resident reported Mirtazapine caused drowsiness, dizziness, and feeling “loopy,” and a physiatrist recommended reducing the dose from 15 mg to 7.5 mg, but the full dose continued to be given. Another resident had ordered Hydralazine for HTN, but the MAR showed three missed doses with no nursing note explaining why they were not administered.
Failure to timely address and communicate significant weight loss. A resident had repeated hospital transfers/readmissions and showed major weight loss on facility weights, including a 12.7% loss followed later by another 6.7% loss. The RD documented weight loss and added nutrition interventions, but there was no evidence the changes were reported to the family or attending MD. Interviews showed conflicting staff understanding of who was responsible for notifying family/providers, and the DON, ADON, and Regional DON validated the concern.
Missing competency records were found for three staff members after a review of employee files and interviews. A GNA rehired after resigning had no competency documentation on rehire, and two RNs had no records verifying clinical skill competency. The Business Officer said HR verifies competency records for new hires and nursing completes annual evaluations, but a joint file review confirmed no skills or competency evaluations were present, and the NHA and DON validated the concern.
Surveyors found unlabeled and expired meds in a nurse med cart and the med room fridge. An LPN had Fluticasone nasal spray and Aplisol with no open-date labels, along with expired oral solutions, while an ADON was present when multiple expired meds were observed in the med fridge, including Cath-Flo, Trulicity, Tresiba, Gabapentin, IV Daptomycin, Novolin N, and IV Imipenem/Cilastatin. An RN said expired meds should be checked weekly and with each med pass, and the DON said night shift nurses are responsible for daily checks.
A resident reviewed for dental concerns had no documented dental consults since admission. The DON stated that no dental visit was obtained because there were no complaints from the resident or family, even though an outside dental evaluation was required on an annual basis.
Meal service times were not kept within the required interval for residents receiving trays. Dinner on the last cart was delivered at 5:20 PM and breakfast on the first cart was delivered at 7:40 AM, creating a 14 hour and 20-minute gap. The Food Service Manager said the assisted living cart time did not count and acknowledged the issue.
The facility failed to ensure that required key personnel were documented as present at monthly QA/QAPI meetings. Review of attendance sheets showed missing documentation for the Infection Preventionist, Medical Director, and DON at several meetings, and the NHA confirmed the absence of documentation during interview.
The facility failed to maintain infection control practices in the laundry room and in multiple resident rooms. In the laundry area, personal items, drinks, and phones were observed on the clean folding table, and only gloves were seen on the dirty side; the laundry aide said she had not been trained on PPE use and no gowns were provided. In addition, 14 of 31 resident rooms did not have alcohol-based hand sanitizer available, and the DON stated the sanitizers had been removed during painting and renovation.
Missing nurse aide training records showed the facility did not track required aide education or ensure completion of annual training, including abuse prevention and dementia care. Two GNA files reviewed lacked evidence of dementia training, including one aide rehired after resignation and another aide hired without documentation of dementia training upon hire. The Regional DON stated the prior DON kept the records and the facility was having difficulty locating or organizing them.
A resident reported possible abuse during an investigation, but the facility did not follow up or document any further inquiry into the allegation. The acting DON was unaware of the claim, and the resident later denied current abuse, but the initial lack of investigation led to a deficiency.
Two residents had care plans that were not reviewed or updated as required, with the most recent updates occurring several months prior to the survey. The DON confirmed that the quarterly care plan reviews were overdue for both individuals.
The facility was found to have deficiencies in maintaining a safe and clean environment for residents. Observations during a survey revealed marring on walls in several rooms, dirty floors, and a bathroom with unsanitary conditions, including a strong ammonia odor. The DON and Maintenance Director were informed, with the latter attributing the issues to high staff turnover.
The facility failed to provide written notification to residents or their representatives regarding hospital transfers. In four reviewed cases, the facility did not issue the required written transfer forms, and residents or their representatives were not informed in writing about the reasons for the transfers. Staff interviews confirmed that the facility's practice was to provide verbal notifications only, indicating a systemic issue in handling hospital transfers.
The facility's kitchen failed to maintain food integrity by not labeling and dating opened food items. Observations revealed undated and expired items in the refrigerator, dry storage, and cooking areas. The CDM confirmed the expectation for proper labeling, and the surveyor discussed these concerns with facility leadership.
A facility failed to maintain a resident's Advanced Directives in their medical record. Despite procedures to review and request these documents upon admission, the facility did not have a copy of the resident's Power of Attorney. This deficiency was identified during a review of the resident's electronic medical record, which lacked documentation of Advanced Directives.
The facility failed to include care plan goals in the documentation during resident transfers, affecting two residents hospitalized. The DON confirmed that care plans were not sent, and LPNs followed a checklist that did not include care plans. A review of the checklist confirmed this omission.
The facility failed to notify residents and their representatives in writing of the bed hold policy during hospital transfers. This was evident for three residents whose records lacked documentation of written notification. Interviews confirmed that the policy was communicated verbally and not automatically provided in writing.
A facility failed to accurately code a resident's MDS assessment, reflecting their functional status inaccurately. The resident, with a history of hemiplegia and hemiparesis, was initially assessed as requiring partial assistance for toileting, but later assessments showed total dependence. The MDS Coordinator admitted the coding error, citing fluctuating assistance needs and a recent change in facility ownership as contributing factors.
A facility failed to implement a care plan for a resident identified as high risk for wandering and elopement. The resident's medical record showed wandering behavior and a high elopement risk score, yet no care plan was in place to address these issues. The facility's policy mandates care plans for such risks, but this was not followed, as confirmed by the DON and a Corporate Designee.
A facility failed to ensure accurate documentation of a resident's code status, resulting in conflicting orders between the EHR and a paper MOLST form. The EHR indicated 'Attempt CPR,' while the paper form stated 'No CPR, Option B, Palliative and Supportive Care / DNR.' The discrepancy arose because the outdated MOLST form was not voided when a new one was created, leading to confusion about the resident's code status.
A facility failed to provide activities based on a resident's preferences and care plan, as the resident with dementia was observed without activity stimulation. Despite the care plan's focus on cognitive stimulation, the activity log showed only two activities for the month, with no refusals documented. Interviews revealed a lack of proper documentation and communication between the Activities Director and Assistant.
The facility failed to properly assess and treat a resident with an unknown injury, did not implement physician orders for another resident's fall precautions, and neglected to assess a third resident upon readmission. An LPN did not perform a thorough assessment or report an incident, leading to a hospital transfer for a resident with a laceration and sprained knee. Another resident's order for bilateral floor mats was not followed, and a third resident was not assessed upon readmission, as required by policy.
The facility failed to conduct competency evaluations for three GNAs, as required by their protocol. Despite being hired at different times, none of the GNAs had evaluations on file, which should occur annually and at the 90-day mark for new hires. The DON confirmed the requirement, and the COO acknowledged the absence of these evaluations.
The facility did not post the required nursing staffing data on the Daily Staffing Schedule for six days. The posted staffing sheet lacked the facility's census and the actual and total hours worked by GNAs, LPNs, and RNs. This issue was confirmed with the Chief Operations Officer, highlighting non-compliance with staffing data posting regulations.
The facility failed to ensure that the attending physician or DON documented and signed in the medical record to show they had reviewed irregularities or recommendations identified by the pharmacist during the MRR. This deficiency was evident in three residents investigated for unnecessary medications, psychotropic medications, and medication regimen review. The clinical pharmacist identified irregularities and made recommendations, but there was no documentation of review or action taken by the attending provider or DON within the required timeframe.
A facility failed to limit a PRN order for hydroxyzine, a psychotropic medication, to 14 days as required by policy. This was discovered during a review of a resident's medical record, which showed an active order without the necessary limitation. The deficiency was confirmed through staff interviews and policy review.
The facility failed to ensure the safe storage of medications and medical supplies. Expired items, including Banatrol Plus and Curad Xeroform dressings, were found in the medication room, along with leftover medications for two residents. In the medical supply room, expired Jevity Complete Balanced Nutrition bottles were noted. The DON confirmed these findings and removed the expired items.
The facility failed to serve meals according to predetermined menus that incorporated resident preferences. During a meal service, three residents did not receive the meals as indicated on their meal tickets. A resident requested a peanut butter and jelly sandwich, which was not provided, another received rice not listed on their ticket, and a third was served rice instead of the indicated roasted red skin potatoes. Staff confirmed these discrepancies, and the issue was reviewed with the facility.
A facility failed to maintain accurate physician orders for a resident receiving 2 liters of oxygen by nasal cannula. Staff confirmed the resident had been on continuous oxygen for a long time but could not find a physician's order authorizing this treatment. A review of the medical record revealed no such order, and staff acknowledged the oversight, indicating the physician would be notified for clarification.
The facility did not have an onsite Infection Preventionist Designee to oversee its Infection Prevention and Control Program. The DON, new to the facility, was set to attend training, while a certified Corporate Infection Control Designee was assisting remotely. The requirement for an onsite Infection Preventionist was acknowledged, and hiring efforts were underway.
The facility failed to maintain essential patient care equipment, with three hand sanitizer dispensers found empty or unsecured and a DS Smart vital sign machine non-functional due to improper connections. Staff confirmed the machine was broken and acknowledged a shortage of working vital sign equipment, impacting the ability to obtain resident vital signs.
A resident was found with a bleeding lip in another resident's room, and the LPN failed to report the injury as required by the facility's policy. The resident was later hospitalized for a laceration and a sprained knee. The deficiency was identified during a survey, highlighting the failure to follow protocol for reporting injuries of unknown sources.
The facility did not submit the required direct care staffing information based on payroll data to CMS for the quarter. This deficiency was identified during a review of the CASPER PBJ Staffing Data Report, and an interview with the COO revealed that the incident occurred under the previous ownership. The issue was discussed during the exit meeting with the surveyor.
Advance Directive and Incapacity Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident or responsible party was offered the opportunity to develop an advance directive for a resident who was cognitively alert and oriented on admission. Review of the resident’s record showed a social service note with no information about advance directive status, and the baseline care plan left the advance directive section blank and was not completed until about one month after admission. During interview, the Social Worker stated that advance directive status should be assessed on admission and documented in the social work progress notes, and validated the absence of that documentation in the resident’s record. The facility also failed to ensure that two certificates of incapacity included a diagnosis or reason for incapacity. One resident’s Physician Certification of Capacity was signed by the attending physician and a nurse practitioner but did not include a diagnosis or clinical reason for incapacity. Another resident had two certificates of incapacity; the first was signed by a physician but did not include a diagnosis or reason, while the second included dementia as the reason for incapacity. The DON and Regional DON reviewed the forms and acknowledged that providers must document the specific reason for incapacity on the certification forms.
Baseline Care Plans and Care Plan Documentation Not Completed or Shared on Time
Penalty
Summary
Facility staff failed to ensure baseline care plans were completed within 48 hours of admission for residents #8 and #15, and failed to document that the BLCP summary and current medication list were delivered to the resident and/or representative. For resident #8, the EMR contained a BLCP section, but the medication list reconciliation, confirmation that the medication list was provided, physician orders, BLCP summary, and signature sections were blank. For resident #15, the BLCP was not created until one month after admission, and the BLCP summary and signature sections were not completed; although staff signature was present, required resident information was missing. Facility staff also failed to provide evidence that care plans were developed and shared appropriately for residents #9 and #40. For resident #9, care plans were developed the same day as admission, the first care plan meeting occurred 8 days later, and the MDS was completed after the meeting rather than before it; the social worker stated that initial care-plan meetings were set up on admission and that copies were only documented if requested, but the record showed no evidence the family received a copy. For resident #40, the first care plan invitation located in the record was sent months after admission, and there was no evidence in the EHR that a copy of the care plans was provided to the resident and/or family.
Care Plan Meetings Not Held or Documented as Required
Penalty
Summary
The facility failed to ensure that care plan meetings were held concurrently with quarterly care plan revisions and that residents and/or their representatives were invited to care plan meetings. The deficiency involved six residents reviewed during the recertification/complaint survey, including residents with long-term stays, recent admissions, and residents with care plans for issues such as falls and other ongoing needs. Survey review found that care plans were not consistently tied to the required assessment and meeting process, and in some cases care plans were developed before the care plan meeting or before the MDS assessment that should have informed them. For Resident #5, MDS assessments were completed on the expected quarterly and annual schedule, but the documented care plan meetings did not align with those assessments, and one assessment period had no corresponding care plan meeting documentation. For Resident #17, quarterly and annual MDS assessments were completed, but care plan meetings/revisions were documented only for some periods, with no documentation for the January and April 2025 assessment periods. Staff interviews confirmed that the Social Worker was responsible for scheduling meetings based on the MDS ARD and that meetings were supposed to occur within one week of the ARD, but the facility acknowledged missing documentation and that the Social Work department was being monitored more closely. Resident #51 stated they had not attended or been invited to a care plan meeting since admission, and record review found no documentation that a care plan meeting had been held or that the resident or family had been invited. For Resident #9, care plans were developed on the day of admission without evidence of resident or family involvement, the first care plan meeting occurred after the care plans were already written, and the MDS was completed after that meeting. For Resident #7, only two care plan meetings were documented during the year despite quarterly meetings being expected. For Resident #40, a falls care plan was initiated and later revised, but there was no evidence of a care plan meeting when it was initiated and no meeting documentation except for one social work note.
Failure to Support Resident Choice in Dining and Weight-Related Care
Penalty
Summary
The facility failed to facilitate resident self-determination through support of resident choice for one resident reviewed for dining-related concerns. The resident reported that food portions were too small and said the resident had been asking for larger portions but the facility refused. The resident was also served mashed potatoes even though the meal slip listed roasted red skin potatoes, which were the resident’s choice, and the resident did not learn of the change until the tray was served. The dietician stated the resident was ordered to receive double portions and described that as a little bit of everything, approximately half of an additional portion. She also stated that at a care plan meeting on 12/26/25, the team discussed the resident’s high BMI, that the resident was eating well, and agreed to keep the resident’s weight stable. When asked whether the resident agreed to a weight loss plan, the resident said no and stated that although the resident had lost close to 180 pounds since admission at almost 400 pounds, the resident was never asked if he/she wanted to lose weight.
Missing Chairs and Damaged Furniture in Resident Rooms
Penalty
Summary
The resident right to a safe, clean, comfortable, and homelike environment was not maintained on one nursing unit when a room had no chairs and another room had damaged furniture. During the initial tour, survey staff observed that room 205 did not have any chairs and room 206 had a bedside table with chipped edges. On a later tour, survey staff again observed that the room had no chairs, leaving visitors and the residents without a place to sit. In the other room, the bedside table for B bed remained chipped around the edges, and the plastic edging from the footboard of B bed was later observed off its track and dangling from the footboard. The Administrator confirmed the missing chairs and the chipped bedside table and stated that both issues would be fixed immediately.
Failure to Promptly Address Resident Grievance
Penalty
Summary
The facility failed to make prompt efforts to resolve a resident grievance involving a roommate conflict and family safety concerns. Resident #5’s family reported that Resident #41 was standing over the resident in an intimidating manner and described additional behavioral issues, including taking other residents’ items, appearing undressed, and blocking doorways. The family stated they did not feel safe with the roommate and requested a room change, but the request was not taken seriously at the time. A progress note documented that Resident #5’s family requested a room change because Resident #41 continued to enter the resident’s personal space and bother them. RN #13 stated that a nurse aide reported a conflict between the two residents and that the nurse went to the room to de-escalate the situation, but no aggressive behavior was observed. RN #13 confirmed that after documenting the family’s request, no further steps were taken at that time. The resident’s room was changed later, after the family’s request had already been made. The DON provided only one grievance form for Resident #5, related to a bed issue, and Staff #25 confirmed the facility should have addressed the room change request timely.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was free from unnecessary medications and chemical restraints. This deficiency was identified for one resident reviewed for unnecessary medication regimens during the recertification/complaint survey, where psychotropic medications were used without adequate clinical indications for use. The resident had diagnoses including Lewy Body Dementia, Parkinson's disease, anxiety, and depression. The medication orders included clozapine 12.5 mg in the morning, clozapine 25 mg in the evening, and clonazepam 0.5 mg at bedtime. During interview, the Psychiatric Nurse Practitioner stated clonazepam should be used for schizophrenia or anxiety and suggested the resident might have schizophrenia symptoms, but review of the attending provider's documentation and past medical history showed no diagnosis or clinical documentation of schizophrenia to justify the regimen. The Psychiatric Nurse Practitioner validated that there was no documented indication for the current antipsychotic and benzodiazepine regimen relative to the resident's specific diagnoses.
Inaccurate MDS Coding for Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure that MDS assessments were accurately coded for one resident reviewed for active diagnoses and unnecessary medications. The resident’s medical record showed diagnoses including Lewy Body Dementia, Parkinson’s disease, anxiety, and depression, but the most recent MDS did not code psychiatric or mood disorders in Section I, which includes anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, and PTSD. During interview, the MDS Coordinator confirmed that the resident’s most recent MDS only coded dementia and Parkinson’s disease and stated that the other mental health conditions, including anxiety and depression, were missed because the records from providers were not fully captured. The Regional Director of Nursing was later informed of the concern and validated the findings.
Failure to Provide Needed Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary assistance to maintain good grooming and personal hygiene. During observation, the resident was found lying in bed with outgrown fingernails that had brown stains on the inside, unshaven facial hair about 4 inches long with dry food particles stuck in it, thick toenails protruding about 3/4 inch long, and a hospital gown with brownish stains on the chest area. A shirt and pants were placed on the baseboard at the foot of the bed, and the resident appeared unkept. On a later observation, the resident was again in bed wearing only a diaper and was not wearing personal clothing. The fingernails and toenails were still not trimmed and had brown stains underneath. The care plan documented an ADL self-care deficit related to infection and included interventions to assist with grooming, keep nails short, and provide daily body checks with AM care. A GNA stated that grooming was the GNA's responsibility and said the resident's son had requested a shower, with grooming to be done during the shower. The ADON later confirmed the nails were dirty and outgrown, the facial hair needed trimming, and the resident looked unkept.
Failure to Follow Physician Recommendations and Administer Ordered Medications
Penalty
Summary
The facility failed to act on a consulting physician’s recommendation for a resident who was receiving Mirtazapine 15 mg at bedtime for depression and poor appetite. The resident reported that the medication made them drowsy and unable to wake up or function normally, and also described dizziness and feeling “loopy” after starting it. A consulting physiatrist documented that the resident complained of significant loopiness and dizziness, recommended reducing the Mirtazapine dose to 7.5 mg to improve tolerance while still providing therapeutic benefit, and noted that the resident agreed and that the recommendation was discussed with the ADON. The record review did not show that the facility acknowledged or acted on that recommendation, and the resident continued to receive the full 15 mg dose each night on the MAR. The facility also failed to administer a prescribed antihypertensive medication as ordered for another resident. The physician ordered Hydralazine HCL 25 mg by mouth every 8 hours for hypertension, but the January MAR showed three missed administrations that were not signed off: one dose on 1/7/26 at 2200, one on 1/16/26 at 2200, and one on 1/17/26 at 0600. Review of the nurse’s notes did not show any explanation for why the medication was not given. During interview, the DON confirmed that unsigned doses meant the medication was not given and agreed that the lack of documentation and missed doses were a concern.
Failure to Timely Address and Communicate Significant Weight Loss
Penalty
Summary
The facility failed to timely address and communicate significant weight loss for one resident reviewed for nutrition. Resident #5 had a pattern of hospital transfers and readmissions, and the medical record showed a weight of 185 lbs on 9/02/25 followed by 161.4 lbs on 9/11/25, a loss of 23.6 lbs (12.7%). The record later showed 165 lbs on 9/18/25, 166.2 lbs on 10/17/25, and then 155 lbs on 10/23/25, a loss of 11.2 lbs (6.7%). The resident’s family stated the resident did not receive adequate hydration and had multiple hospital transfers. The RD documented on 9/19/25 that weight loss had been noted on readmission and may have been due to nutrient intake less than needs, with interventions including bedtime cookies and pudding and 30 ml of liquid protein twice daily. On 10/24/25, the RD recommended a re-weight and additional liquid protein. However, there was no evidence in the record that the significant weight changes were reported to the family or the attending physician. During interviews, the DON stated the RD notifies the family and contacts providers regarding changes, while the RD stated she only provides recommendations to facility staff and does not contact families or providers directly. The ADON stated it was the dietitian’s role to notify the family of changes in condition, and the surveyor’s concerns about the lack of evidence of timely communication were validated by the ADON and Regional DON.
Missing Nursing Competency Documentation
Penalty
Summary
The facility failed to implement a system to ensure nursing staff were competent in their respective skill sets, as shown by a review of employee files and staff interviews. During the review of five randomly selected staff competency records, three files were found deficient: one GNA who had been rehired after resigning in December 2025 had no documentation of competency upon rehire, and two RNs hired in December 2024 had no records verifying clinical skill competency. The Business Officer stated that HR verifies competency records for new hires and the nursing department conducts annual evaluations, but a joint review of the files confirmed that no skills or competency evaluations were present for the three staff members. The NHA and DON were informed of the findings and validated the concerns.
Unlabeled and Expired Medications Found in Med Cart and Fridge
Penalty
Summary
Drugs and biologicals in the facility were not appropriately labeled and stored in accordance with accepted professional standards. During observation of the pink hall nurse med cart with an LPN, surveyors found Fluticasone Propionate nasal spray and Tuberculin Purified Protein Derivative Diluted/Aplisol with no labels indicating when they were opened. The same cart also contained expired Levetiracetam oral solution and expired H-Chlor solution. In the med room, an ADON was present when surveyors observed expired medications stored in the med refrigerator. These included Cath-Flo Activase injection, Trulicity pen, Tresiba FlexTouch, Gabapentin liquid, three bags of IV Daptomycin, Novolin N FlexPen, and IV Imipenem/Cilastatin, all noted as expired. An RN stated that expired medications are supposed to be checked weekly and with each medication administration, and that expired medications should be discarded and replaced. The DON stated that night shift nurses are responsible for checking the med room fridge and med carts daily and acknowledged the concern.
Failure to Obtain Dental Services
Penalty
Summary
Provide or obtain dental services for each resident was not met for one resident reviewed for dental concerns. Resident #10’s clinical record was reviewed and showed the resident had been admitted, but there were no dental consults documented since admission. During interview, the DON stated that no dental consult or visit had been obtained because there had been no complaints from the resident or family. The surveyor informed the DON that the regulation requires an evaluation from an outside source on an annual basis, and the DON stated understanding of the finding.
Meal Service Times Exceeded 14 Hours Between Dinner and Breakfast
Penalty
Summary
Meals and snacks were not served at times in accordance with resident needs, preferences, and requests because the facility failed to ensure meals were served less than 14 hours apart for residents receiving a meal tray. A review of meal service times showed that dinner was delivered on the last food cart at 5:20 PM and breakfast was delivered on the first breakfast cart at 7:40 AM, creating a 14 hour and 20-minute gap between meals. During interview, the Food Service Manager stated that the time listed for the food cart delivered to assisted living did not count, and she acknowledged the finding and said she understood the meal timing issue.
Missing Required Members at QA Meetings
Penalty
Summary
The facility failed to ensure that key essential personnel were present during monthly Quality Assurance (QA) meetings. Review of the QAPI meeting attendance sheets from February 2025 to the present showed that three of eight monthly meetings lacked documentation of attendance by required members. The Infection Preventionist was not documented as attending the 04/30/25 meeting, the Medical Director had no documented attendance for the 06/25/25 meeting, and the Director of Nursing had no evidence of attendance for the December 2025 meeting, which was not clearly dated. During an interview, the Nursing Home Administrator reviewed the attendance sheets with the surveyor and validated the absence of documentation for these key personnel.
Infection Control Lapses in Laundry Room and Missing Hand Sanitizers in Resident Rooms
Penalty
Summary
The facility failed to ensure that laundry staff used appropriate infection control measures in the laundry room. During an inspection of the laundry room, personal items were observed on the clean folding table, including a black handbag, an animal print material, two cell phones, two clear plastic soda cups, and an open bottle of Pepsi cola. On the dirty side of the laundry area, only gloves were observed, with no gown or mask available for sorting or handling dirty laundry. In an interview, the laundry aide stated that dirty laundry was not sorted because it came in a special laundry bag and was placed directly into the washer with the clothing. She said only gloves were used, that no gowns were provided by the facility, and that she had not been taught to use gowns when handling dirty laundry. She also stated she had not received training on infection control and PPE use and had not been told not to leave personal items, food, or drinks on the clean folding table. The housekeeping director stated that laundry staff were supposed to receive monthly infection control training and that gloves, gowns, and facemasks were expected for heavily soiled linens, and confirmed that no food, drinks, or personal items should be on the clean folding table. The facility also failed to have hand sanitizers available in 14 of 31 resident rooms. Observation of rooms on two halls showed multiple rooms without hand sanitizers, and a CMA confirmed that staff were expected to perform hand hygiene before entering or leaving resident rooms and between resident care, with sanitizers normally located on the walls or in resident rooms. The interim DON stated that the sanitizers had been removed during painting and renovation and that they were supposed to be placed in each resident room.
Missing Nurse Aide Training Records
Penalty
Summary
The facility failed to implement a process for tracking nurse aide participation in required training and did not ensure that all aides received the mandated 12 hours of annual training, including abuse prevention and dementia management. Administrative record reviews showed that two of two Geriatric Nursing Assistants reviewed had missing dementia training documentation: GNA #29 was hired in December 2024, resigned, and was rehired in December 2025, but there was no evidence of dementia training upon re-hire, and GNA #32, hired in April 2025, had no records showing dementia training upon hire. Staff #25, the Regional DON, stated that the previous DON maintained the training records and that the facility was having difficulty locating or organizing them, adding that only the training found in the files could be located. Staff #25 validated the absence of dementia training records for newly hired staff.
Failure to Investigate Resident's Allegation of Abuse
Penalty
Summary
The facility failed to appropriately respond to an alleged violation of abuse reported by a resident during an ongoing investigation into another incident. During a review of records related to a facility-reported incident, it was discovered that a resident had answered affirmatively to all questions on the Resident Interview form for abuse, but no further comments or additional information were documented regarding the claim. There was no evidence that the facility followed up on the resident's statements or initiated an investigation into the possible abuse as required. When questioned, the acting DON was unaware of the resident's prior claim and indicated that the previous DON had conducted the interviews at the time. The resident was later interviewed by the surveyor and recalled the situation, stating that the staff member involved was no longer employed at the facility and denied any current concerns or abuse. Despite the resident's current denial of abuse, the initial failure to investigate the reported allegation constituted a deficiency in the facility's response to potential abuse.
Failure to Review and Revise Resident Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that care plans for residents were reviewed and revised at least quarterly and as necessary to address changes in residents' conditions. Record review showed that for two residents, the most recent care plans were significantly outdated, with one last updated in March and the other in April, despite the current review taking place in October. During an interview, the Director of Nursing confirmed that the quarterly care plans for both residents were overdue. This deficiency was identified during a complaint survey and was based on both documentation and staff interview.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as observed during a survey conducted on multiple dates. During an entrance tour, several rooms were found with marring on the walls, including Rooms #200, #201, #203, #204, #205, and #206. Additionally, Rooms #204 and #208 had dirty floors with dark substances noted throughout. A specific bathroom was observed with a yellow water substance around the base of the toilet, wet dark brown stains on the floor extending up the wall, flaking paint, and a strong ammonia odor. The Director of Nursing was informed of these observations, and later, the Maintenance Director acknowledged the issues, citing a high turnover of environmental staff as a contributing factor. The Maintenance Director committed to addressing the concerns by touring the affected hallway and beginning work on the identified areas. The administrative team was also made aware of these deficiencies at the time of the survey exit.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents or their representatives regarding the reasons for their transfer to the hospital. This deficiency was identified during a survey, which reviewed the cases of four residents who were hospitalized. In each case, the facility did not provide the required written transfer forms, and the residents or their representatives were not informed in writing about the reasons for the transfers. Interviews with staff, including the President of a sister company and the Business Office Manager, confirmed that the facility's practice was to provide verbal notifications only, and written notifications were not automatically provided. The surveyor's review of the medical records for the residents revealed a lack of documentation indicating that the residents or their representatives were notified in writing about the transfers. The Director of Nursing and the Business Office Manager confirmed during interviews that the facility did not send written notifications for transfers or discharges. This failure to provide written notification was consistent across all reviewed cases, indicating a systemic issue within the facility's procedures for handling hospital transfers.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The kitchen at the facility failed to maintain the integrity of food items by not properly labeling and dating opened food products. During an initial observation of one of the kitchen refrigerators, several items were found to be improperly stored. These included orange slices, dijon mustard, a block of yellow American cheese, and containers of mayo, relish, and chopped garlic, all of which were either past their use-by dates or undated. Additionally, an unidentified food item was found, which the cook was unable to recognize and subsequently discarded. Further inspection of the dry storage area revealed multiple opened and undated food items, including pasta bags, a box of rice, a bag of croutons, cereal bags, and a container of oats. The Certified Dietary Manager (CDM) confirmed that the expectation was for all opened items to be labeled with the date they were opened and their use-by date. In the cooking area, opened and undated items such as peanut butter, soy sauce, and oil were also found and discarded by the CDM. The surveyor discussed these concerns with the CDM, Director of Nursing, and the Nursing Home Administrator, highlighting the failure to ensure proper food storage practices.
Failure to Maintain Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a copy of a resident's Advanced Directives was obtained and maintained in the resident's medical record. This deficiency was identified during a review of the electronic medical record of a resident, where no documentation of Advanced Directives was found. The resident's record included a Social Services note indicating that the Resident Representative was also the Power of Attorney (POA), and an Admission Contract signed by the Resident Representative in the designated space for the POA. The contract stated that if the resident had an Advance Directive, a copy should be provided to the facility. During an interview with the Business Office Manager, it was revealed that the facility's procedure involves reviewing Advanced Directives with the resident or their representative upon admission and requesting a copy if one exists. This document is then supposed to be uploaded into the resident's electronic medical record, and the resident's profile updated to reflect the authoritative title. However, the facility was unable to provide a copy of the resident's Power of Attorney, indicating a lapse in their system for managing and maintaining these critical documents.
Failure to Include Care Plans in Resident Transfers
Penalty
Summary
The facility failed to include resident care plan goals with the required documentation during transfers, as evidenced by the cases of two residents reviewed for hospitalization. Resident #55 was hospitalized on two occasions, and Resident #37 was hospitalized on another occasion. In both instances, the Director of Nursing confirmed that care plans were not sent with the residents upon transfer from the facility. Interviews with two Licensed Practical Nurses (LPNs) revealed that they follow a transfer checklist to determine what documents to send with a resident, but the checklist did not include care plans. A review of the blank transfer checklist confirmed the absence of care plans as a required document for transfer. At the time of the survey exit, the surveyor discussed the concern regarding the failure to ensure care plans are sent with residents upon transfer.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to have a system in place to ensure that residents and/or their representatives were notified in writing of the bed hold policy at the time of discharge or transfer to a hospital. This deficiency was identified during a survey, where it was found that three out of four residents reviewed for hospitalizations did not receive written notification of the bed hold policy. Specifically, Resident #41's electronic medical record did not contain documentation indicating that the resident or their representative was notified in writing of the bed hold policy upon transfer to the hospital. Interviews with the Director of Nursing and the Business Office Manager confirmed the absence of such documentation. Similarly, Resident #55 was hospitalized on two occasions, and the facility was unable to provide a copy of the written bed hold policy form for one of the hospitalizations. The form from the other hospitalization lacked the resident's signature or any indication that the resident was informed. Interviews revealed that the policy was communicated verbally and not automatically provided in writing. Resident #37 also experienced hospitalizations, and the facility could not provide copies of the written bed hold policy forms for these events. The Business Office Manager confirmed that the policy was not sent to the family and was only available upon request.
Inaccurate MDS Coding for Resident's Functional Status
Penalty
Summary
The facility failed to ensure accurate coding of a resident's assessment by the MDS Coordinator, which did not reflect the resident's actual status at the time of the assessment. This deficiency was identified during a survey investigation for a resident with a history of hemiplegia, hemiparesis, and malignant neoplasm of the larynx. The MDS assessment completed on 06/14/24 indicated that the resident required partial assistance for toileting. However, a subsequent quarterly assessment showed a decline in the resident's functional status, indicating total dependence on staff for toileting assistance. The MDS Coordinator acknowledged that the coding on the quarterly assessment did not accurately reflect the resident's functional status. She explained that the resident's needs fluctuated between requiring minimal and maximum assistance, and she had coded the resident's needs somewhere in the middle. The discrepancy was attributed to a recent change in facility ownership, which required reviewing information from the old system to determine the resident's decline. The administration team was informed of these concerns at the time of the survey exit.
Failure to Implement Care Plan for Wandering and Elopement Risk
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident identified as high risk for wandering and elopement. This deficiency was discovered during a survey when reviewing the electronic medical record of a resident who exhibited wandering behavior and expressed a desire to go home. The resident's medical record included a skilled progress note indicating the resident was walking aimlessly and refusing redirection. An Elopement Evaluation note further identified the resident as high risk for elopement with a score of 3. Despite these findings, the resident's care plans did not include any strategies or interventions to address the wandering and elopement risk. The facility's policy requires that residents identified as at risk for wandering or elopement have a care plan in place to ensure their safety. During an interview with the Director of Nursing and a Corporate Designee, it was confirmed that no care plan had been initiated for the resident's wandering and elopement risk.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to maintain an effective system for ensuring accurate documentation of resident code status regarding Cardiopulmonary Resuscitation (CPR). This deficiency was identified for one resident, who had conflicting code status orders in their medical records. The resident's Electronic Health Record (EHR) indicated a code status of 'Attempt CPR,' while a paper MOLST form in the nursing station binder indicated 'No CPR, Option B, Palliative and Supportive Care / Do Not Resuscitate (DNR).' The inconsistency arose because the MOLST form dated earlier was not voided when a new form was created, leading to conflicting information about the resident's code status. Interviews with the Director of Nursing (DON) revealed that the facility did not have hard paper charts and relied on the EHR for resident MOLST forms and code status. However, MOLST forms were also kept in binders at the nursing station and with the Social Worker. The DON acknowledged that the MOLST forms should reflect one another and that outdated forms should be voided when new ones are created. The failure to void the outdated MOLST form resulted in a discrepancy between the EHR and the paper MOLST form, leading to confusion about the resident's code status orders.
Failure to Provide Resident-Specific Activities
Penalty
Summary
The facility failed to provide activities to a resident based on their preferences and care plan, as evidenced by the case of one resident reviewed for activities. The resident, who has cognitive deficits related to dementia, was observed on multiple occasions without any activity stimulation, despite their care plan indicating the need for cognitive stimulation. The resident's preferences included reading materials, music, news, pets, and coloring, but the activity log showed only two documented activities for the entire month, with no records of refusals. Interviews with the Activities Director and Assistant revealed that while they claimed to visit residents daily and document activities or refusals, the documentation for this resident was lacking. The Activities Director acknowledged the deficiency in the activity log and had communicated expectations to the assistant. The surveyor noted the concern regarding the failure to provide activities based on the resident's interests and care plan during the exit review.
Failure to Assess and Implement Orders for Residents
Penalty
Summary
The facility failed to ensure proper assessment and immediate treatment for a resident who sustained an injury of unknown origin. A resident was found in another resident's room with a bleeding lip, but the LPN on duty did not perform a thorough assessment, notify the family or physician, or report the incident to administration. The resident was later transferred to the hospital, where a laceration requiring sutures and a sprained knee were diagnosed. This incident highlights a lack of adherence to protocol in assessing and reporting injuries. Additionally, the facility did not implement physician orders for another resident who required bilateral floor mats as a fall precaution. Observations revealed that only one floor mat was in place, contrary to the active order. The DON acknowledged the discrepancy, noting that the other side posed a fall risk to the resident's ambulatory roommate. Furthermore, a third resident was not assessed upon readmission to the facility, as required by the facility's policy. The lack of documentation for the admission assessment was confirmed by the Corporate Infection Control Designee, indicating a failure to follow established procedures for new or readmitted residents.
Failure to Conduct Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that all nursing staff had competency evaluations, as evidenced by the lack of such evaluations for three Geriatric Nursing Assistants (GNAs) out of five randomly selected staff members. Specifically, GNA #10, hired in March 2024, GNA #30, hired in August 2016, and GNA #31, hired in June 2018, did not have any competency evaluations on file. According to the Director of Nursing, competencies should be conducted annually and at the 90-day mark for new hires. However, the Chief Operations Officer confirmed that no performance evaluations could be found for these staff members, indicating a lapse in the facility's adherence to its competency evaluation protocol.
Failure to Post Required Nursing Staffing Data
Penalty
Summary
The facility failed to post the required nursing staffing data on the Daily Staffing Schedule for six consecutive days during the survey. Observations made by the surveyor on multiple days revealed that while a staffing sheet was posted, it did not include the facility's census or the actual and total number of hours worked by Geriatric Nursing Assistants (GNAs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs). This deficiency was confirmed during a review with the Chief Operations Officer, indicating non-compliance with the required nursing staff data posting regulations.
Failure to Document Review of Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician or Director of Nursing (DON) documented and signed in the medical record to show they had reviewed irregularities or recommendations identified by the pharmacist during the Medication Regimen Review (MRR). This deficiency was evident in three out of five residents investigated for unnecessary medications, psychotropic medications, and medication regimen review. The clinical pharmacist identified irregularities and made recommendations for these residents, but there was no documentation of review or action taken by the attending provider or DON within the required timeframe. For Resident #19, the pharmacist made recommendations on multiple occasions from February to September 2024, but the attending physician only reviewed the recommendations from August and September in October 2024. Similarly, for Resident #41, recommendations made in July and September 2024 were not reviewed within 30 days. Resident #50 also had recommendations made in May, June, July, and September 2024, with no documentation of review or action taken. The DON confirmed that the MRR policy had not been followed for some time, and there was a lack of timely review and documentation of the pharmacist's recommendations.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility staff failed to comply with the policy regarding the limitation of PRN orders for psychotropic medications to 14 days. This deficiency was identified during a review of a resident's medical record, which revealed an active order for hydroxyzine, a medication used to control anxiety and tension, prescribed as needed every 8 hours. The order, dated 9/19/24, did not include a 14-day limitation as required by the facility's policy. This oversight was confirmed during a staff interview and a review of the facility's policy on psychotropic medication use.
Failure to Safely Store Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure the safe storage of medications and medical treatment supplies, as observed by the surveyor. In the medication room, expired items were found, including a box of Banatrol Plus and packs of Curad Xeroform Petroleum dressing. Additionally, medications such as Sodium Polystyrene Sulfonate and Ceftriaxone Sodium injection solution were left over after their prescribed courses for two residents, and an opened, undated vial of Lidocaine was also present. These medications were confirmed by the Director of Nursing (DON) and Corporate Designee to be unused and should have been returned to the pharmacy or destroyed. In the medical supply room, labeled as the linen room, the surveyor noted expired bottles of Jevity Complete Balanced Nutrition with Fiber. The DON confirmed the presence of these expired bottles during an interview and subsequently removed them from the supply room. These observations indicate a failure in the facility's protocol for monitoring and managing the expiration and storage of medications and medical supplies.
Failure to Serve Meals According to Resident Preferences
Penalty
Summary
The facility failed to ensure that residents were served meals according to predetermined menus that incorporated their preferences. This deficiency was observed during a meal service where three residents did not receive the meals as indicated on their meal tickets. Resident #32 requested a peanut butter and jelly sandwich, which was noted on their meal ticket, but it was not included on their tray. Similarly, Resident #8's meal ticket did not list rice, yet rice was included on their tray. Resident #17's meal ticket indicated roasted red skin potatoes as the starch, but they were served rice instead. The surveyor confirmed these discrepancies through observations and interviews with staff members, including a GNA and the Certified Dietary Manager (CDM). The CDM acknowledged that the expectation was for residents to receive meals as specified on their meal tickets. The surveyor reviewed these findings with the facility at the time of exit, highlighting the failure to ensure residents received meals according to their documented preferences and dietary needs.
Failure to Maintain Accurate Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to maintain accurate physician orders for the use of oxygen for a resident. During observation rounds, the resident was observed to be on 2 liters of oxygen by nasal cannula. Staff confirmed that the resident had been receiving oxygen continuously for a long time but could not find a physician's order authorizing this treatment. A review of the resident's medical record revealed no physician orders for the administration of oxygen. Staff acknowledged the absence of a physician order and indicated that the physician would be notified for clarification.
Lack of Onsite Infection Preventionist
Penalty
Summary
The facility failed to have an Infection Preventionist Designee onsite to oversee the Infection Prevention and Control Program. During the entrance conference, the Administrator and the Director of Nursing (DON) revealed that the DON, who had been at the facility for about a month, was scheduled to attend an Infection Control training class. In the meantime, the facility was relying on a Corporate Infection Control Designee who is certified but does not work onsite. The Administrator was informed that the Infection Control Designee must be present at the facility and not operate in an off-site corporate capacity. An interview with the Corporate Infection Control Designee confirmed her awareness of the requirement for the Infection Preventionist to work onsite, and she mentioned that the facility was in the process of hiring for this position.
Deficiency in Equipment Maintenance
Penalty
Summary
The facility failed to maintain essential patient care equipment in safe and working conditions, as observed during a survey. Three hand sanitizer dispensers located outside rooms #108 to #115 were found to be either empty or not properly secured to the wall. Additionally, a DS Smart vital sign machine was observed to be non-functional, as it would not turn on and had connection wires that did not fit properly. Staff confirmed the machine was broken and acknowledged a shortage of working vital sign equipment on the floor, which hindered the ability to obtain resident vital signs effectively.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of an unknown source for a resident, which was discovered during a survey. The incident involved a resident who was found in another resident's room with a bleeding lip. A Geriatric Nursing Assistant (GNA) found the resident and informed a Licensed Practical Nurse (LPN), who cleaned the resident's face but did not conduct a further assessment or notify the family, physician, or administration. The LPN also failed to write an incident report. The facility's policy requires that injuries of an unknown source be immediately reported to the administration, which was not done in this case. The resident was later transferred to the hospital, where it was determined that they had a laceration on the upper lip requiring sutures and a sprained right knee. The facility's failure to report the injury promptly and follow the established protocol for such incidents was identified as a deficiency during the survey. The surveyor confirmed with the facility's Administrator that the LPN should have reported the injury immediately, as per the facility's abuse policy.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required direct care staffing information based on payroll data to the Centers for Medicare/Medicaid Services (CMS) for the quarter. This deficiency was identified during a review of the CASPER Payroll-Based Journal (PBJ) Staffing Data Report document from CMS, which revealed the absence of the necessary submission. An interview with the Chief Operations Officer indicated that this incident occurred under the previous ownership of the facility. The issue was further discussed during the exit meeting with the surveyor, highlighting the facility's failure to comply with the staffing data submission requirements.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
