Snow Hill Rehabilitation & Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Snow Hill, Maryland.
- Location
- 430 West Market Street, Snow Hill, Maryland 21863
- CMS Provider Number
- 215121
- Inspections on file
- 17
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Snow Hill Rehabilitation & Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to ensure a functioning call bell system on two nursing units, where call lights above resident rooms were illuminated but no audible alerts were heard by staff. On one unit, the call bell panel behind the nurse’s station had tape covering the enunciator speaker and was set to a low tone that was not audible to staff or residents. On the other unit, an illuminated call light corresponded with a panel that had tape over the enunciator speaker, a nonfunctional enunciator, and a missing low/high tone switch. The director of maintenance reported being unaware of these issues until informed by surveyors, and the administrator and DON were notified of the nonfunctioning systems during the survey.
Nursing staff failed to follow MD-ordered BP and pulse parameters before administering cardiac medications for two residents. For one resident deemed unable to make medical decisions, Midodrine was given despite SBP readings above the ordered threshold at multiple administrations. For another resident with ESRD on hemodialysis, osteomyelitis, and AFib, Amiodarone and Metoprolol were repeatedly administered even when SBP and/or HR were below the specified hold parameters, as shown in MAR and clinical record reviews conducted during a complaint survey.
Staff failed to immediately report an allegation of suspected abuse to law enforcement after a resident’s family reported that an LPN had told staff not to provide care and not to administer pain medication. The facility’s investigation documented that the resident, who had a BIMS score indicating adequate cognition, reported not receiving pain medication, but the facility concluded the allegation was unsubstantiated and that care and pain medication were provided as ordered. Despite an abuse policy requiring timely reporting of all alleged or suspected abuse to the State Agency and other required agencies, including law enforcement, the allegation was not reported to police or other state agencies, a fact confirmed by the administrator.
A resident with depression, a positive trauma screen, and a history of PTSD had physician orders for psychological/psychiatric evaluation and care plans addressing depression and behavior issues, including yelling out instead of using the call bell. After an alleged incident in which an LPN told staff not to provide care or pain medication to the resident, the facility conducted an abuse investigation and determined the resident should be referred to Geri-Psych services. Despite this determination and the existing order for psychiatric evaluation, the resident was never assessed by the facility’s Geri-Psych consultant, as confirmed by the DON.
A resident’s closed clinical record lacked complete and accurate documentation related to controlled substances and medication administration. During a complaint survey, staff were unable to produce certain controlled substance administration records, and the DON reported that the Oxycodone controlled substance record for a range of dates could not be located. Review of the Oxycodone 5 mg tablet MAR showed missing nurse signatures and assessments for multiple administered doses. The report emphasizes that documentation is an integral part of medication administration and that inaccurate documentation has the potential to place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers.
Surveyors found that food items, including mashed potatoes, chicken, eggs, sausage, and bacon, were served below required temperatures, and frozen juice was placed on breakfast trays. Temperature logs were incomplete, and beverage temperatures were not consistently recorded, as confirmed by staff interviews and record review.
The facility designated the ADON as its Infection Preventionist without ensuring she had completed the required specialized infection control training. Documentation showed she had only recently enrolled in a training course and was still on the first module, with no other qualified staff available for the role.
Surveyors found that several dependent residents did not receive required ADL care, including oral hygiene, assistance with dressing, and shaving. Observations included a resident with a dry mouth and unbrushed teeth despite physician orders, another with soiled clothing left unchanged, and a resident with unshaven facial hair. Staff interviews and record reviews confirmed that these residents required substantial or total assistance with ADLs, but care was not provided as needed.
Surveyors found expired and undated medications on two medication carts, including expired tablets, suspensions, and injection pens, as well as multi-use medications that were opened but not dated. The consultant pharmacist confirmed these deficiencies, and the DON reported that routine checks for expired and unlabeled medications were not performed due to staffing changes.
Surveyors identified multiple deficiencies in food storage and preparation, including staff not wearing hair nets, incomplete temperature logs, opened and unlabeled food items, personal food stored with facility food, pest issues, and contamination in both refrigerators and freezers. Expired food and unsanitary conditions were also found in the nourishment room, with these issues confirmed by the Dietary Manager and DON.
Surveyors found that a resident's nebulization mask was left uncovered and unlabeled on a nightstand, and oxygen tubing with a nasal cannula was nearly touching the floor. Additionally, clean bed sheets were observed touching the floor during folding by both a housekeeper and a laundry aide, despite staff awareness of proper procedures. These incidents reflect lapses in infection prevention and control practices.
The facility failed to maintain records for abuse and neglect investigations for three residents, leading to deficiencies in addressing alleged violations. In one case, a resident was found with another resident's hand on their clothed thigh, but the facility did not investigate. In another, a family member grabbed a resident around the neck, but no investigation report was found. In the third case, the facility could not provide the investigation file for a reported incident of abuse or neglect.
Two residents were not informed of their shower schedules and expressed a lack of awareness despite repeated inquiries. Staff interviews revealed confusion about documentation and the location of completed shower sheets, and the ADON confirmed the issue when notified that residents were unaware of their scheduled shower days.
A resident was admitted without a baseline care plan being developed or provided within the required 48-hour timeframe. Staff interviews indicated that the DON or ADON were responsible for creating these plans, but the process was not completed as required, resulting in a deficiency.
A resident was observed receiving oxygen via nasal cannula, but no care plan addressing oxygen use was found in their records. The DON confirmed that while care plans are usually initiated and updated as needed, the required care plan for oxygen therapy was not developed or implemented for this resident.
A resident with multiple diagnoses, including dementia and muscle weakness, was admitted and assessed as needing assistance with ADLs such as toileting, dressing, and personal hygiene. Despite this, no care plan was in place to address these needs, as confirmed by the DON during a surveyor interview.
Surveyors found that the facility did not perform ordered lab tests for a resident, failed to administer insulin according to prescribed sliding scale orders for another resident, and did not set up required pacemaker monitoring equipment for a third resident. Nursing staff were unaware of the need for cardiac monitoring, and documentation for lab draws and medication administration was incomplete or inconsistent with physician orders.
Two residents with pressure ulcers did not receive necessary care as staff failed to implement and document recommended interventions such as frequent turning, use of pressure-relieving devices, and heel elevation. Despite having physician orders and care plans in place, staff did not consistently follow these protocols, as confirmed by observations, interviews, and record reviews. The lack of standard protocols and inconsistent implementation led to deficiencies in pressure ulcer management.
A resident identified as being at risk for dehydration was found without access to water at the bedside or on the meal tray during a meal. The only available beverage was not suitable for the resident, and staff confirmed that the water pitcher had not been delivered as per facility protocol, despite a care plan intervention to encourage fluid intake.
Surveyors found that multiple residents receiving oxygen therapy did not have their oxygen tubing or humidification bottles labeled with the date of use, and required signage indicating oxygen in use was missing from room entrances. Additionally, one resident was receiving oxygen without a physician order, despite facility policy requiring such orders. These deficiencies were confirmed by interviews with LPNs and review of medical records.
A resident received PRN pain medications, including acetaminophen and oxycodone, without specific pain parameters outlined in the physician orders. Nursing staff administered these medications based on individual judgment rather than standardized guidelines, resulting in inconsistent pain management practices. The DON confirmed that the facility lacked a system for specifying pain parameters in PRN orders, leading to variability in care.
Surveyors found that two GNAs did not have documentation of the required 12-hour annual in-service training in their employee files. The HRD confirmed the absence of current in-service records and stated that a new training program had not yet started.
The facility did not include all required information on the posted nurse staffing sheet, omitting the resident census and the total number and actual hours worked by each category of licensed and unlicensed nursing staff. Staff interviews confirmed that the posted sheet only showed assignments and not the actual hours worked, and the HR director acknowledged the missing information.
A resident with a history of trauma and at risk for post-traumatic syndrome did not receive necessary behavioral health care services. Although care plans identified the risk and outlined monitoring goals, there was no evidence of a PTSD evaluation or consistent behavior monitoring, as confirmed by interviews and record reviews.
A resident did not receive monthly Medication Regimen Reviews (MRRs) as required, and the facility failed to implement the pharmacist's recommendations to monitor the resident's A1C levels for diabetes management. The necessary lab orders were not completed, and the last A1C result was not current, as confirmed by the DON.
A resident prescribed Abilify for psychosis and Lexapro for depression did not have required behavior monitoring documented on the TAR, despite facility policy and an active care plan calling for such monitoring. The DON confirmed that behavior monitoring for psychotropic medications was not being performed for this resident.
Three residents were not screened for or offered pneumonia vaccinations, and there was no documentation of vaccine administration or refusal. Facility policy requires assessment and offering of pneumococcal immunization upon admission, but staff could not explain the lack of documentation or confirm if the outside pharmacy had provided the vaccines.
Surveyors identified that required in-service training, including dementia care and abuse prevention, was not documented as completed for several GNAs. The HR Director confirmed the incomplete records and acknowledged that a new training program had not yet started, with no further documentation provided during the survey.
Nonfunctional Call Bell System on Two Nursing Units
Penalty
Summary
The deficiency involves the facility’s failure to maintain a functioning, house-wide resident call bell system on both nursing units, resulting in call lights being illuminated without an accompanying audible alert to staff. During observation of the Cypress Unit, the surveyor noted resident call bell lights lit above rooms, but no audible signal was heard to indicate residents were requesting assistance. Closer inspection of the call bell panel behind the nurse’s station showed tape covering the enunciator speaker and the enunciator set to a low tone that, after several seconds, produced a sound that was not audible to the surveyor, staff, or residents on the unit. On the Federal Unit, the surveyor observed a resident call bell light illuminated above a room with no audible alert, and the call bell panel behind that unit’s nurse’s station had tape over the enunciator speaker, a nonfunctional enunciator, and a missing low/high tone switch. The director of maintenance stated that they were not aware of these call bell system issues until the surveyor raised the concern, and the administrator and DON were informed of the nonfunctioning call bell systems on both units during the survey. No specific resident medical histories or clinical conditions were described in the report, and the deficiency centers on the environmental and equipment failures related to the call bell system and the lack of prior awareness by facility leadership and maintenance staff.
Failure to Follow BP and Pulse Parameters for Cardiac Medications
Penalty
Summary
Nursing staff failed to follow physician-ordered blood pressure parameters for administration of Midodrine for one resident. The resident had been deemed incapable of making all medical decisions by two physicians and had a physician’s order dated 01/16/26 for Midodrine 10 mg orally three times a day, to be given only when the systolic blood pressure (SBP) was less than 100 mmHg and to be held when SBP was greater than 100. Review of the January 2026 MAR showed that staff administered Midodrine despite SBP readings above the ordered threshold, including doses given when SBP was documented as 102/57, 108/62, and 101/60. Nursing staff also failed to follow physician-ordered blood pressure and pulse parameters for administration of Amiodarone and Metoprolol for another resident with diagnoses including end stage renal disease on hemodialysis, difficulty walking, osteomyelitis, and atrial fibrillation, who had been deemed capable of making all medical decisions. A physician’s order for Amiodarone 200 mg orally every 12 hours directed staff to hold the medication if SBP was less than 110 or heart rate was less than 60, yet MAR review showed multiple doses given when SBP was below 110 and/or pulse was below 60. A separate order for Metoprolol 25 mg orally twice daily directed staff to hold the medication if SBP was less than 100 or heart rate was less than 60, but MAR review again showed multiple administrations when SBP and/or pulse were below the ordered hold parameters, including an instance with SBP 81/40. These findings were identified through review of closed and active clinical records and MARs during a complaint survey and shared with facility leadership at exit.
Failure to Report Alleged Abuse to Law Enforcement
Penalty
Summary
Facility staff failed to immediately report an allegation of suspected resident abuse to local law enforcement as required. On 08/31/25, a nursing staff member (LPN #1) allegedly told a resident’s nursing staff not to provide care and stated that pain medication would not be administered to the resident. The resident later informed his/her responsible party that nursing staff had not medicated him/her with pain medication. The responsible party reported this concern, and the facility initiated an investigation. The resident’s Brief Interview for Mental Status (BIMS) score was documented as 13/15 on 06/10/25, indicating the resident had the capacity to report concerns. The Office of Health Care Quality (OHCQ) received a facility-reported incident on 09/05/25 regarding these allegations. A 5-day follow-up investigation report dated 02/03/26 documented the allegation and the facility’s conclusion that the allegation was unsubstantiated, stating that the resident had received care and pain medication as ordered on 08/31/25. Review of the facility’s abuse policy showed that all alleged or suspected abuse, including verbal and mental abuse and neglect, must be reported to the State Agency and all other required agencies, including law enforcement, in a timely manner. Further review of the facility’s follow-up investigation revealed that the allegation was not reported to law enforcement or any other state agencies beyond OHCQ. During an interview on 02/04/26, the administrator confirmed that law enforcement had not been notified of the abuse allegation involving this resident.
Failure to Obtain Psychiatric Evaluation After Abuse Allegation and Positive Trauma Screen
Penalty
Summary
Facility staff failed to obtain a psychiatric consultation for Resident #3 despite multiple indicators and orders requiring such services. The resident had diagnoses including muscle atrophy, lack of coordination, difficulty walking, depression, gout, and osteomyelitis, and had been deemed capable of making medical decisions by the physician. On 12/06/24, the resident screened positive for a history of trauma and past PTSD, and a depression care plan was initiated the same day, identifying the resident as at risk for depression with a positive trauma screen. Interventions in the care plan directed staff to notify the provider for any risk of harm to self or others and to observe for signs of depression such as hopelessness, anxiety, sadness, tearfulness, and repetitive anxious or health-related complaints. On 03/26/25, a physician’s order instructed nursing staff to obtain a psychological/psychiatric evaluation upon admission and as needed due to the positive trauma screen. On 08/31/25, an incident occurred in which an LPN allegedly told other nursing staff not to provide care to Resident #3 and stated that pain medication would not be administered. Following this, the facility conducted an abuse investigation related to these allegations. The resident also had a behavior care plan initiated on 09/02/25 for yelling out for assistance instead of using the call bell, with interventions including discussing the behavior with the resident when reasonable, explaining why the behavior was inappropriate, anticipating and meeting needs, monitoring episodes of behavior, and documenting behaviors and potential causes. Despite the physician’s order for psychological/psychiatric evaluation and the facility’s determination during its follow-up investigation that the resident should be referred to the facility Geri-Psych service provider, the DON confirmed that the resident was never assessed by the Geri-Psych consultant after the abuse allegation was brought to the facility’s attention.
Incomplete Controlled Substance and MAR Documentation for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident, specifically related to controlled substances and medication administration documentation. During a complaint survey, a nurse surveyor reviewed the closed medical record of Resident #3 and requested all closed paper documents and access to the electronic medical record. Several documents were found to be missing from the clinical record, and facility staff were unable to produce certain documentation, including medication administration records (MARs) and controlled medication records. The nursing staff did not document the number of Oxycontin 10 mg tablets destroyed on the resident’s controlled substance administration record on 09/21/25. In an interview on 02/04/26, the DON stated they were unable to locate the resident’s Oxycodone controlled substance administration record for dates between 09/05/25 and 09/24/25. Additionally, a review of the resident’s Oxycodone 5 mg tablet MAR for August and September 2025 showed missing nursing administration signatures and nursing assessments for doses that were given on specific dates and times, including 08/25/25 at 4 pm, 09/01/25 at 10:30 pm, and 09/02/25 at 1:15 pm and 6:15 pm. The report notes that documentation is an integral part of medication administration and that inaccurate medication documentation has the potential to place residents at significant risk of medication error and provide incomplete or inaccurate information for providers and caregivers to evaluate.
Failure to Serve Food and Beverages at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors observed that the facility failed to ensure food and beverages were served at safe and appropriate temperatures. During multiple kitchen observations, hot foods such as mashed potatoes, mechanical ground chicken, fried chicken, pureed eggs, ground sausage, and bacon were found to be below the required internal temperatures for safe consumption. The Dietary Manager and staff were seen attempting to reheat some items, but even after reheating, several foods still did not reach the necessary temperatures. Additionally, food temperature logs were incomplete, with missing entries for certain dates and meals. Surveyors also noted that frozen cranberry juice was placed on residents' breakfast trays and served to residents, rather than being at an appropriate temperature for consumption. Review of the Meal Service Checklist revealed that juice temperatures were not recorded for several weeks. These deficiencies were confirmed through observation, interviews with dietary staff and the DON, and review of facility records.
Infection Preventionist Lacks Required Training
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for the position. The Assistant Director of Nursing (ADON), who was serving as the IP, confirmed during an interview that although she holds a college degree in nursing, she had not completed specialized training in infection control as required. Documentation reviewed included an email and a computer screenshot showing that the ADON had only recently registered for an Infection Prevention and Control course and was currently on the first module. The Director of Nursing (DON) also confirmed that the ADON was the only individual currently serving as the IP and that no one else in the facility was qualified for the position.
Failure to Provide ADL Care to Dependent Residents
Penalty
Summary
The facility failed to provide necessary activities of daily living (ADL) care to dependent residents, as evidenced by multiple observations and record reviews. One resident, who was dependent on staff for all ADLs due to upper and lower extremity impairment and was NPO, was repeatedly observed with a dry mouth, yellow teeth, and a thick coating on the tongue. Clinical records confirmed a physician's order for oral care every shift, but interviews and observations revealed that oral care had not been completed as required. Another resident was observed lying in bed with dried food particles on the gown, which remained unaddressed for an extended period despite staff being notified. This resident required maximum assistance for dressing and personal hygiene according to the admission assessment. Additionally, a resident requiring assistance with ADLs was observed with significant facial hair and reported not receiving help with shaving since admission. Staff confirmed that shaving assistance should have been provided but was not. A further resident with dentures, requiring substantial to maximal assistance for oral hygiene, was found to have an unused toothbrush still in its packaging. Both the resident and a family member reported that oral care had not been provided since admission. Staff interviews revealed a lack of awareness regarding which residents required assistance with dentures, and repeated observations confirmed that oral care was not performed as needed.
Failure to Properly Label and Store Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were properly labeled and stored, as required by professional standards. During observations of two medication carts, expired medications and opened medications without dates were found. Specific examples included expired tablets, suspensions, cough suppressants, injection pens, and inhalation aerosols. Additionally, several multi-use medications, such as insulin pens and ophthalmic solutions, were found opened but not dated, making it impossible to determine their expiration. These deficiencies were confirmed through interviews with the consultant pharmacist, who stated that expired medications should be removed and multi-use medications should be dated upon opening. The facility's own Medication Storage Document indicated that consultant pharmacists are responsible for routinely inspecting for discontinued, outdated, or improperly labeled medications. However, the Director of Nursing reported that the Night Charge Nurse, who typically checks medication carts for expired and unlabeled medications, had been reassigned to direct care duties and was unable to perform this supervisory role. The pharmacy was noted to conduct monthly audits, but expired and undated medications were still present at the time of the survey.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and preparation practices. During a kitchen tour, staff members were seen preparing food without wearing hair nets. Temperature logs for both the reach-in fridge and beverage refrigerator were not completed daily, with several days missing entries. Inside the reach-in fridge, multiple opened food items were found unlabeled, including sliced turkey, cheese, and vegetables, as well as personal food items that should not have been stored there. A container of mozzarella cheese with a broken lid and an outdated label was also found. In the dry storage area, several food items such as peanut butter, instant mashed potatoes, noodles, and bread were found opened and undated, and the Dietary Manager acknowledged ongoing pest issues in the facility. Further observations revealed additional concerns in the freezer, where an unknown substance had dripped onto food items, contaminating an open bag of ice and waffles. Multiple opened and unlabeled food items were found, including leftovers and personal beverages. The outside freezer had water icicles dripping onto food due to a faulty gasket, causing temperature fluctuations. In the nourishment room, expired milk and sandwiches were found, along with personal food in the fridge and a dirty ice scoop holder. These findings were confirmed by the Dietary Manager and DON during the survey.
Deficiencies in Infection Control: Improper Storage of Respiratory Equipment and Laundry Handling
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control program related to the handling and storage of respiratory equipment and the management of clean laundry. For one resident, a nebulization mask was observed left uncovered and unlabeled on a nightstand when not in use, contrary to facility expectations that such devices be stored in a clean, labeled bag. Additionally, the same resident's oxygen tubing was seen hanging from the concentrator with the nasal cannula exposed and nearly touching the floor. These observations were confirmed by nursing staff during the survey. In a separate incident, clean bed sheets were observed touching the floor during the folding process in the laundry room on multiple occasions. Both a housekeeper and a laundry aide were seen allowing sheets to contact the floor while folding, with the laundry aide acknowledging awareness of the proper procedure but citing difficulty due to her height. The housekeeping supervisor confirmed that clean laundry should not touch the floor and that folding should be done on a table.
Failure to Maintain Abuse and Neglect Investigation Records
Penalty
Summary
The facility failed to maintain records for abuse and neglect investigations for three residents, leading to deficiencies in addressing alleged violations. In the first case, a resident was found with another resident's hand on their clothed thigh, but the facility did not investigate the incident. The resident involved had a diagnosis of dementia and was adjusting to a new environment. Despite the incident being reported to the Office of Health Care Quality, the facility could not provide documentation of an investigation, and staff members were unaware of the incident. In the second case, a staff member observed a family member grab a resident around the neck after the resident refused a kiss. The facility was unable to locate the investigation report for this incident, and the current Nursing Home Administrator, who was not employed at the time, could not find any documentation. An activities aide reported the incident to her supervisor and the NHA at the time, but no evidence of a thorough investigation was provided. The third case involved a reported incident of abuse or neglect, but the facility could not provide the investigation file. The current NHA, who was not in the position at the time of the incident, was unable to locate the file or any documentation of staff in-services on abuse and neglect. The facility's policy required prompt investigation and documentation of such incidents, but no evidence was found to support compliance with this policy.
Failure to Inform and Support Resident Choice in Shower Scheduling
Penalty
Summary
The facility failed to provide residents with the opportunity to choose or be informed about their shower schedules, as evidenced by interviews and record reviews. Two residents reported not knowing their shower schedules, with one stating they had been in the facility for several weeks and had repeatedly asked staff for information without receiving an update. Another resident expressed a desire to know their schedule. Review of physician orders showed that one resident had scheduled shower days, while the other did not have an order in place. Staff interviews revealed that GNAs received assignments with highlighted shower days at the start of their shifts, but there was confusion regarding the location and availability of completed shower sheets. A GNA was unable to provide completed documentation, and the LPN stated that alert and oriented residents were aware of their schedules, though this was contradicted by resident interviews. The ADON confirmed the lack of accessible shower sheets and acknowledged awareness of the issue when informed that residents were not aware of their shower days.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident within 48 hours of admission, as required. Record review showed that the resident was admitted on 1/31/25, but there was no evidence in the medical record that a baseline care plan was created or provided to the resident. Interviews with staff revealed that the DON or ADON were typically responsible for developing baseline care plans, while nurses would add interventions in the electronic health record. The DON confirmed that the baseline care plan was not completed in a timely manner for this resident.
Failure to Develop and Implement Oxygen Therapy Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was receiving oxygen therapy via nasal cannula at 2 liters per minute. During the recertification survey, it was observed that the resident was using oxygen, but a review of the care plan revealed no documentation or evidence that a care plan addressing oxygen use had been created. Interviews with the DON confirmed that care plans are typically initiated upon admission and updated as needed, but in this case, the necessary care plan for oxygen therapy was not present. The deficiency was identified through direct observation, record review, and staff interview.
Failure to Develop Care Plan for ADL Needs
Penalty
Summary
The facility failed to develop or revise a care plan to address the activities of daily living (ADL) needs for one resident. The resident was admitted with multiple diagnoses, including hypotension, diabetes, dementia, and muscle weakness. According to the Minimum Data Set (MDS) admission assessment, the resident required assistance with ADLs such as toileting, dressing, showering, and personal hygiene. However, a review of the clinical records revealed that there was no care plan in place to address these specific needs. During an interview, the Director of Nursing (DON), who also served as the MDS coordinator, acknowledged responsibility for initiating care plans and confirmed that a care plan for ADLs should have been established for the resident. The absence of a care plan was identified during the surveyor's review, indicating that the facility did not meet the requirement to develop or revise care plans to address the resident's assessed needs.
Failure to Follow Physician Orders for Labs, Medication Administration, and Cardiac Monitoring
Penalty
Summary
The facility failed to ensure that physician laboratory orders were performed as ordered for a resident who required weekly CBC and CMP blood tests. Despite an active order for these labs to be drawn every Tuesday for four weeks, the medical records showed that the tests were not performed for three consecutive weeks. Documentation revealed that while other blood tests were marked and drawn, the CBC and CMP were not, and the phlebotomist's signature was crossed out for those tests, confirming they were missed. Additionally, the facility did not administer medications as ordered for a resident requiring insulin based on blood glucose levels. The Medication Administration Record (MAR) lacked documentation of the resident's blood glucose level on a day when insulin was held, making it unclear if the medication was withheld appropriately. On another occasion, the MAR showed a blood glucose level of 470, but the insulin dosage administered did not match the physician's sliding scale order, which required a higher dose for such elevated levels. The facility also failed to provide proper cardiac monitoring for a resident with a pacemaker. The resident and family reported that the pacemaker monitoring system had not been set up since admission several months prior, and observations confirmed the equipment remained unused in the resident's closet. Interviews with assigned nursing staff revealed a lack of awareness regarding the resident's pacemaker and the need for bedside monitoring, despite care plans and medical records indicating the presence of a pacemaker and the requirement for monitoring.
Failure to Implement and Document Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the necessary treatment and that recommended interventions were implemented. For one resident, wound clinic recommendations included the use of a low air-loss mattress, turning and repositioning every two hours, floating heels at all times, and using pillow boots to offload pressure. However, a review of active physician orders showed that these pressure-relieving interventions were not written or implemented. Interviews with nursing staff and the DON confirmed that there were no standing orders or standard protocols for pressure ulcer management, and that interventions were handled on a case-by-case basis or only after wound clinic visits. Another resident with an unstageable pressure ulcer on the coccyx was observed not being turned or repositioned as required, and their heels were not floated despite orders and care plan interventions specifying these actions. The resident and their family member both reported that necessary tasks such as turning, repositioning, and heel elevation were not being performed. Observations confirmed that the heel floating device was not in use and was instead stored under the sink, and the resident had not been assisted out of bed as ordered. Record reviews for both residents showed that appropriate orders and care plan interventions were in place, including frequent turning, use of specialized cushions, and heel elevation. Despite these documented interventions, staff failed to consistently implement them, as evidenced by direct observation, resident and family interviews, and staff interviews. This failure resulted in the residents not receiving the necessary care to promote healing and prevent the development or worsening of pressure ulcers.
Failure to Provide Bedside Water for Resident at Risk of Dehydration
Penalty
Summary
A deficiency was identified when a resident, who was care planned as being at risk for dehydration, was observed without access to drinking water at the bedside or on the meal tray during lunch. The resident expressed to the surveyor that the only available beverage was too sweet and that water was not provided. Upon further inquiry, a Geriatric Nursing Assistant (GNA) confirmed that water is typically provided in pitchers at the bedside, filled by the night shift, but acknowledged that the resident in question did not have a water pitcher delivered. The Charge Nurse also confirmed the absence of water and explained that water is not placed on meal trays because it is assumed to be available at the bedside. Review of the resident's clinical record showed an active care plan intervention to encourage fluid intake due to dehydration risk. The Director of Nursing (DON) confirmed the facility's practice of providing water pitchers at the bedside and stated that it is the responsibility of GNAs and Charge Nurses to ensure pitchers are refilled. The deficiency was substantiated by direct observation and staff interviews, which revealed a lapse in the delivery of water to the resident, despite facility protocols and the resident's identified risk for dehydration.
Failure to Label Oxygen Equipment and Ensure Physician Orders for Oxygen Therapy
Penalty
Summary
Surveyors identified that the facility failed to provide necessary respiratory care services for residents requiring oxygen therapy. Specifically, oxygen administration equipment such as tubing and humidification bottles were not labeled with the date they were put into use or when they should be replaced for multiple residents. Additionally, there was no signage placed outside the residents' rooms to indicate that oxygen was in use, as required by facility policy. These deficiencies were observed during multiple visits and confirmed through interviews with nursing staff, who acknowledged that labeling and signage were expected practices. Further review revealed that one resident was receiving oxygen therapy without a corresponding physician order, contrary to the facility's policy that oxygen must be administered under a physician's direction. The affected residents had significant respiratory diagnoses, including acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and chronic respiratory failure. Despite the presence of physician orders for oxygen therapy for some residents, the lack of proper labeling, absence of required signage, and missing physician order for one resident constituted a failure to adhere to established protocols for safe and appropriate respiratory care.
Failure to Specify Pain Parameters for PRN Pain Medication Orders
Penalty
Summary
The facility failed to ensure that pain medications were administered according to professional standards of practice for a resident requiring pain management. Record review showed that the resident had active and discontinued PRN orders for acetaminophen and oxycodone, but none of these orders specified pain parameters to guide administration. Medication administration records indicated that the resident received both Tylenol and oxycodone on multiple occasions, with pain ratings documented at the time of administration. However, there was no clear guidance in the orders regarding which medication should be given at specific pain levels. Interviews with nursing staff revealed inconsistency in practice, as some nurses relied on their own judgment to determine which PRN pain medication to administer when parameters were not specified. The LPN interviewed stated that she would give oxycodone for pain ratings above 7 and Tylenol for pain ratings below 5, but this was not based on any written protocol. The DON confirmed that the facility did not have standardized pain parameters in place for PRN pain medications and that the process depended on individual physician orders, which were not always present. This lack of clear parameters led to inconsistent pain management practices for the resident.
Failure to Complete Required Annual GNA In-Service Training
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) completed the required 12 hours per year of in-service training, as evidenced by a review of two GNA employee files. During the survey, it was found that neither of the two GNA files contained documentation of current annual in-service training. The Director of Human Resources confirmed that the required in-service training had not been completed and that a new training program had not yet been initiated. No documentation of the required in-service training was provided to the surveyor at the time of exit.
Failure to Post Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information on the nursing unit included all required elements. During a tour of the nursing unit, the surveyor observed that the daily staffing sheet, while displaying the facility name, staff names, assignments, date, and shift, did not include the resident census or the total number and actual hours worked by each category of licensed and unlicensed nursing staff responsible for resident care per shift. This omission was confirmed through interviews and review of the posted staffing sheet. Staff interviews revealed that the posted sheet was primarily used to indicate staff assignments for the shift, but did not provide information on the actual hours worked by each staff member. Both a Geriatric Nursing Assistant and an LPN confirmed that the sheet did not display the required details regarding hours worked. The Director of Human Resources, responsible for staffing and scheduling, also acknowledged that the posted sheet was missing the resident census and the total number and actual hours worked by each staff category.
Failure to Provide Behavioral Health Services for Trauma History
Penalty
Summary
A resident with a documented history of trauma and at risk for post-traumatic syndrome did not receive necessary behavioral health care services. The resident reported a lack of behavioral services for their trauma history. Record reviews showed that the resident's care plan identified risks for post-trauma syndrome and mood problems, with goals to monitor and report symptoms such as sadness, loss of interest, and changes in behavior. However, there was no evidence that a specific evaluation for PTSD was completed, despite the resident's risk factors and self-reported trauma history. Interviews with facility staff revealed that the process for residents identified as at risk for PTSD included a trauma screening and scheduling a psychiatric evaluation. Despite this, the resident's psychology consult notes did not document a PTSD evaluation, and behavior monitoring was not recorded on the Treatment Administration Record for the past six months. The deficiency was identified through interviews and record reviews, confirming the facility failed to provide necessary behavioral health care services for the resident.
Failure to Complete Monthly Medication Regimen Reviews and Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a monthly Medication Regimen Review (MRR) for a resident, as required. Record review showed that MRRs were not completed every month, with gaps in the documented review dates. Additionally, the facility did not implement the pharmacist's recommendations from the MRRs regarding the monitoring of the resident's Hemoglobin A1C (A1C) levels, which are important for diabetes management. The pharmacist had recommended checking the resident's A1C immediately and every 3-6 months, and the physician agreed to these recommendations, but the necessary lab orders were not completed as directed. Further review of the resident's records revealed that the last A1C lab value was obtained several months prior, and subsequent lab collections did not include the A1C test as recommended. The Director of Nursing confirmed that the expectation was for the MRR to be completed monthly, indicating that the facility did not follow its own policies and procedures for medication review and follow-up on pharmacist recommendations.
Failure to Monitor Behaviors for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to provide adequate behavior monitoring for a resident who was prescribed psychotropic medications, specifically Abilify for psychosis and Lexapro for depression. Record review showed that although a care plan was in place to address the use of these medications, including interventions such as discussing ongoing need with the physician and family and reviewing behaviors and alternative therapies, there was no evidence on the Treatment Administration Record (TAR) that behaviors were being monitored as required. The Director of Nursing confirmed that behavior monitoring for psychotropic medications was not being conducted for this resident, despite facility policy stating that such monitoring should occur and be documented each shift. This deficiency was identified during a recertification survey and was evident for one of four residents reviewed for unnecessary medications.
Failure to Screen and Offer Pneumonia Vaccinations
Penalty
Summary
The facility failed to screen and offer pneumonia vaccinations to three out of five residents reviewed for immunizations. Medical record review revealed that these residents had no documentation indicating they were screened for, offered, received, or refused the pneumonia vaccine. The facility's policy requires that each resident be assessed for pneumococcal immunization upon admission and be offered the vaccine unless medically contraindicated or previously immunized. During staff interviews, the Assistant Director of Nursing (ADON) acknowledged that the vaccines should have been offered and administered as appropriate, but was unable to explain why this did not occur for the affected residents. The ADON also reported that vaccination services had previously been performed by an outside pharmacy, but she did not have access to those records and was unable to locate documentation for the three residents in question, even after further searching.
Incomplete In-Service Training Documentation for GNAs
Penalty
Summary
The facility failed to ensure that required in-service training for Geriatric Nursing Assistants (GNAs) was completed, as evidenced by incomplete documentation in all five GNA employee files reviewed. During a record review, the surveyor found that none of the files for the selected GNAs contained complete records of the mandated in-service training, including education in dementia care and abuse prevention. The Director of Human Resources confirmed the lack of documentation and acknowledged that a new in-service training program had not yet been initiated. No additional documentation was provided to demonstrate completion of the required training for these GNAs by the time of the survey exit. The deficiency was identified through both employee record reviews and interviews, with the facility unable to provide evidence that the GNAs had received the necessary in-service education as required.
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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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