The Village At Rockville
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 9701 Veirs Drive, Rockville, Maryland 20850
- CMS Provider Number
- 215125
- Inspections on file
- 14
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Village At Rockville during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate two abuse allegations involving injuries of unknown origin by not consistently conducting and documenting resident interviews and assessments. In both cases, initial incident reports listed actions such as initiating investigations, notifying physicians and families, and performing limited clinical assessments, but did not include resident interviews or broader assessments as protective steps. Investigation files contained multiple staff interviews but lacked documented interviews with other residents or clear assessment data tied to the incidents. The NHA acknowledged that interviewing both staff and residents is best practice and believed social services had completed resident interviews, yet could not produce documentation. The DON reported that non-interviewable residents were not interviewed and that monitoring occurred through observation and family contact, but was unable to provide complete assessment records related to the incidents.
A resident with HTN had orders for Amlodipine and Metoprolol with parameters to hold doses if SBP was below 110 and, for Metoprolol, if HR was below 60. Despite this, Metoprolol was administered when the resident’s SBP was 101, and multiple BP readings below the ordered parameter were documented without evidence that the physician was notified or that medications were held as ordered. Separately, maintenance hot water logs showed the same temperature values carried across all resident rooms using lines and arrows instead of recording actual temperatures for each room, and the Maintenance Director acknowledged the logs were not completed accurately.
A facility investigation into an alleged abuse/neglect incident found that a GNA provided care in a rushed and disruptive manner that did not meet acceptable standards of quality. A PDA and a family member reported that the GNA moved quickly, slammed and rapidly opened/closed cabinet doors in a resident’s room, and left a dirty blanket on the bed. The resident also reported that the staff member moved too quickly while providing care. Although abuse was not substantiated, these observations showed that the resident did not receive compassionate, quality care consistent with their preferences and goals.
A resident's MOLST form instructed to attempt CPR, but due to a miscommunication, staff did not initiate CPR when the resident was found unresponsive. The RN relied on a shift report form indicating a DNR status, which was incorrect. The RN supervisor also failed to initiate CPR after verifying the correct code status in the resident's chart. The attending provider later advised against CPR due to the resident's condition.
The facility failed to provide mandatory communication training for direct care staff, including GNAs, LPNs, and an RN. A review of training records for eight randomly selected staff members revealed no documentation of completed communication training. This deficiency was identified during an extended survey following an Immediate Jeopardy situation. The Nursing Home Administrator was informed, but no further evidence was provided.
The facility failed to report allegations of abuse within the required two-hour timeframe for multiple incidents. In one case, a resident alleged being compromised at night, but the report was delayed by over 24 hours. Another incident involved a resident claiming a staff member put their head in a toilet, with a similar reporting delay. Additionally, a resident requiring assistance was refused help by a GNA, and the incident was not reported until the following day. The facility did not initially identify these situations as potential abuse, contributing to the deficiency.
The facility failed to obtain informed consent for bed rail use for two residents. Observations revealed that both residents had bed rails in use, but their medical records lacked consent documentation. The DON stated that consent was part of the assessment process, but no evidence of consent was found. The NHA confirmed the absence of consent for both residents.
The facility failed to ensure pharmacists' recommendations on medication irregularities were communicated to physicians for three residents. Reports were not documented in medical records, and there was no evidence that physicians reviewed or acted on the recommendations, indicating a breakdown in communication and documentation processes.
A resident's call bell went unanswered for over 42 minutes on multiple occasions, despite staff expectations to respond within 8 minutes. Interviews with a GNA and LPN revealed the facility lacked a formal call bell policy, and the DON and NHA acknowledged the deficiency.
A resident who required assistance with transfers was denied help by a GNA after lunch, despite expressing discomfort and a desire to return to their room. The GNA refused to assist and dismissed the resident's requests, leading the resident to attempt to wheel themselves back to their room. Other staff eventually assisted the resident, and the incident was reported the next day. The GNA's actions were confirmed, resulting in her termination.
A facility failed to thoroughly investigate an abuse allegation involving a resident. A family member reported the alleged abuse to a supervisor, but the investigation lacked interviews with the family member, the resident, and the supervisor. The DON acknowledged the missing interviews during a discussion.
A facility failed to notify a primary care provider about a lab result for a resident with a urinary tract infection. A urine specimen was spilled in transit, and although a nurse was informed, there was no documentation of communication with the provider. The nurse's responsibility includes reviewing lab results, notifying the provider, and documenting the communication, which was not done in this case.
The facility failed to maintain a safe environment, with a broken lock on a housekeeping closet and unrepaired drywall in resident rooms. A housekeeping closet was found unlocked, and a hole in a bathroom wall was stuffed with toilet paper. The Maintenance Director was unaware of these issues, and no work orders were found for the damaged drywall.
The facility failed to include a resident's care plan in the transfer documentation during hospitalization. Interviews with LPNs revealed that while a transfer checklist was used, it did not include the care plan. The DON confirmed that care plans should be sent with residents, but this was not being done, resulting in a deficiency.
The facility failed to provide written transfer notices to two residents and their representatives during hospitalizations. For one resident, no written notice was found for two hospitalizations, and verbal notifications were inconsistently documented. For another resident, despite documentation of a hospital transfer due to respiratory distress, there was no evidence of a written notice being provided. The NHA and DON confirmed these deficiencies.
The facility failed to properly orient and document the transfer of two residents to the hospital. One resident's medical records lacked evidence of preparation for hospitalizations, while another resident was transferred for respiratory distress without documentation of being informed about the transfer. The DON confirmed these deficiencies.
The facility failed to provide written notification of its bed-hold policy to residents and their representatives upon transfer to a hospital. For two residents, there was no documentation of written notice, only verbal communication was noted. The facility was unable to produce evidence of written notifications, indicating a systemic issue in compliance with notification requirements.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked measurable goals and non-pharmaceutical interventions for managing psychosis, despite receiving psychotropic medications. Another resident's care plan did not indicate the presence of a hearing aid, even though it was noted in the MDS assessment. The DON confirmed these deficiencies.
A private duty aide, not licensed to feed residents, was observed feeding a resident who required assistance in the dining room. Despite the presence of other staff, no intervention occurred. The aide was hired for another resident and fed the resident multiple times without proper authorization.
A facility failed to provide clear guidelines for administering as-needed medications for constipation to a resident. The resident's MAR included three medications for constipation, with no instructions on which to administer first. Two orders were for the same medication, leading to potential confusion. The issue was acknowledged by the DON.
A facility failed to adequately monitor a resident's behavior and side effects related to psychotropic medication use. The resident, with moderate cognitive impairment and multiple medical diagnoses, was prescribed Duloxetine, Quetiapine, and Lorazepam. Despite orders to monitor behavior, the facility did not document specific behaviors or non-pharmacological approaches, nor did they monitor the resident for behaviors related to the prescribed antipsychotic.
The facility failed to store food items properly, leading to a risk of cross-contamination. A surveyor found a sausage without a label or date in the walk-in freezer, which was removed by the Dining Services Supervisor. Additionally, in the second-floor kitchen, a surveyor observed uncovered and unlabeled salsa and sour cream with a scoop inside. A dining server identified and removed these items after being shown by the surveyor. The Dining Director acknowledged the improper storage.
The facility failed to maintain accurate medical records by not voiding outdated MOLST forms when new ones were created, resulting in multiple active forms with conflicting orders for three residents. This issue was identified during a survey, revealing discrepancies between the electronic medical records and hard charts.
A facility failed to maintain proper infection control practices when a resident's Foley catheter bag was observed lying flat on the floor. A nurse confirmed the observation and acknowledged that the catheter bag should not be in contact with the floor. The nurse adjusted the bed to prevent the catheter from touching the floor, suggesting the bed had been lowered, causing the issue.
The facility failed to educate two residents or their representatives on the risks and benefits of pneumonia vaccinations, as evidenced by the lack of documentation for informed consent. The Infection Preventionist nurse confirmed this deficiency.
Failure to Conduct and Document Resident Interviews and Assessments in Abuse Investigations
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate two separate allegations of abuse related to injuries of unknown origin for two residents. For the first incident involving Resident #74, the initial incident report listed actions such as initiating an investigation and notifying the family, physician, medical director, and ombudsman, but did not include resident interviews or resident assessments as immediate protective steps. Review of the facility’s abuse investigation file showed eight staff interviews but no resident interviews or assessments. The follow-up investigation report also confirmed that only staff were interviewed. During interviews, the Nursing Home Administrator (NHA) acknowledged that including both staff and resident interviews is best practice and stated she believed the social worker had completed resident interviews. The DON reported that they do not interview residents who are considered non-interviewable, instead looking for signs or symptoms of abuse and contacting families, and indicated that any screening would be documented through skin assessments. However, the DON could only produce a limited number of skin assessments for some non-interviewable residents and these were not clearly tied to the abuse investigation. For the second incident involving Resident #140, the initial incident report for an injury of unknown origin documented steps such as initiating an investigation, completing a head-to-toe assessment, medicating for pain, notifying the physician, responsible party, and medical director, ordering an x-ray, and updating the care plan, but again did not list resident interviews or broader resident assessments as part of the immediate protective actions. The abuse investigation file contained nine staff interviews but no documentation of resident interviews or assessments. The follow-up investigation report indicated that only staff and the involved resident were interviewed. The NHA confirmed the investigation file was complete, reiterated that she believed the social worker had conducted resident interviews, and produced an email stating that three residents on the same hallway had been interviewed, but no written interview documentation could be provided. The DON stated they do not interview non-interviewable residents, instead monitoring for signs or symptoms and contacting families, and was unable to provide any documentation of completed resident assessments related to this incident, demonstrating that resident interviews and assessments were not consistently conducted or documented as part of the abuse investigations.
Failure to Follow Antihypertensive Parameters and Accurately Document Hot Water Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice for a resident receiving antihypertensive medications. Review of the resident’s MAR showed orders for Amlodipine 10 mg at bedtime and Metoprolol Succinate ER 50 mg daily for HTN, with instructions to hold both medications if the systolic blood pressure (SBP) was less than 110, and to hold Metoprolol if the heart rate was less than 60. On one morning, RN #28 administered Metoprolol despite the resident’s SBP being 101, which was below the ordered hold parameter. Review of the resident’s blood pressure readings showed multiple SBP values below 110 on several dates, including 103/57, 101/58, 102/57, 94/51, and 98/56. The medical record did not contain documentation that the physician was notified when the resident’s SBP was less than 110 or that the medication was held as ordered. A second deficiency was identified related to maintenance documentation of hot water temperatures. Review of the facility’s hot water logs showed that on multiple dates, a single temperature (ranging from 119°F to 121°F) was recorded with a line and downward arrow drawn through each box for every resident room, instead of documenting the actual temperature for each room. During interview, the Maintenance Director acknowledged that the hot water logs were not completed accurately or completely, confirming that the recorded temperatures did not reflect individual room measurements as required.
Failure to Provide Compassionate, Quality Care During Personal Care Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received care that met acceptable standards of quality, in accordance with orders, preferences, and goals. During review of a facility-reported incident involving allegations of abuse and neglect by a GNA toward one resident, multiple interviews documented concerns about the manner in which care was delivered. A Patient Decision Aide who worked with the resident on two consecutive days reported observing the GNA slamming cabinet doors in the resident’s room, moving quickly while opening and closing doors, and leaving a dirty blanket on the resident’s bed. These observations were recorded as part of the facility’s internal investigation. A family member of the same resident reported observing the GNA rapidly opening and closing cabinet doors in the resident’s room and stated that the GNA did not appear compassionate while providing care. In a separate interview, the resident reported that the GNA “moves too quickly” when providing care. Although the facility’s investigation did not substantiate abuse, the collected interviews consistently described rushed, abrupt care, environmental disruption (slamming and rapidly opening/closing cabinet doors), and failure to maintain a clean bed surface, which together demonstrated that the resident did not receive care that met acceptable standards of quality.
Failure to Initiate CPR Due to Miscommunication of Code Status
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) to an unresponsive resident whose Maryland Orders for Life Sustaining Treatment (MOLST) instructed to attempt CPR in the event of cardiac and/or pulmonary arrest. The incident involved a resident who was found unresponsive by a geriatric nurse aide (GNA) and subsequently assessed by a registered nurse (RN), who noted the resident had cold clammy skin, no rise and fall of the chest wall, and dilated pupils. Despite these observations, the RN did not initiate CPR, as the resident's MOLST form instructed. The failure to initiate CPR was attributed to a miscommunication regarding the resident's code status. The RN relied on a change of shift report form that incorrectly indicated the resident had a Do Not Resuscitate (DNR) order. This misinformation was compounded when the RN supervisor also failed to initiate CPR after checking the resident's physical chart, which correctly indicated the need to attempt CPR. The attending provider was contacted and advised against initiating CPR due to the resident's condition at that time.
Removal Plan
- The staffing agency was notified of the occurrence, and staff #8 was placed on the Do Not Return list for the facility.
- A document review was conducted on all units to ensure code status information was only available on the MOLST form in the residents' physical charts.
- Nursing staff were re-educated on MOLST and the CPR process by the RN unit managers.
- Policy on MOLST and CPR and education were activated in the facility's training software program for nursing staff review and acknowledgment.
- The 3 Unit Managers (Care Coaches) also provided in-person training to all nursing staff.
- The Medical Director provided education to all attending physicians (including Resident #137's attending provider).
- The facility audited and reviewed all residents' MOLST forms and orders.
Lack of Mandatory Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff received mandatory communication training, as evidenced by a review of training records for eight staff members, including Geriatric Nursing Assistants, Licensed Practical Nurses, and a Registered Nurse. During the extended survey portion of the recertification survey, it was discovered that none of the eight randomly selected staff members had documentation of completed communication training. This deficiency was identified following an Immediate Jeopardy situation during the standard survey, prompting a more in-depth review of staff training records. The Nursing Home Administrator was informed of the lack of evidence for mandatory communication training, but no further evidence was provided to address this deficiency.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe for four facility-reported incidents. In one case, a responsible representative informed the facility of an allegation involving female residents being compromised at night, but the report to the Office of Healthcare Quality was delayed by over 24 hours. Another incident involved a resident alleging that a staff member put their head in a toilet, but the report was not made until the following morning. Similar delays were noted in two other incidents, where reports were made several hours after the allegations were initially reported to staff. Additionally, the facility did not identify and report potential abuse involving a resident who required assistance with transfers. The resident requested help from a geriatric nursing assistant (GNA) to return to bed after lunch, but the GNA refused, stating she would assist after dinner. The resident, experiencing discomfort, attempted to return to their room independently until another staff member intervened. The incident was not reported to the state survey agency until the following day, and the Director of Nursing was not informed until the report was sent. The facility's investigation revealed that the Care Coach did not follow up with the resident on the evening of the incident, and the Director of Nursing confirmed that the incident was not initially identified as abuse. The lack of immediate reporting and failure to recognize the situation as potential abuse contributed to the deficiency, as the facility did not adhere to the required protocols for timely reporting and addressing allegations of abuse.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent prior to the initiation of bed rails for two residents. This deficiency was identified during a survey where Resident #120 was observed with bed rails in use, but a review of their medical record did not reveal a consent form for the bed rail use. The Director of Nursing (DON) explained that residents were assessed prior to the initiation of bed rails and that the consent could be found on the assessment form. However, upon review, the surveyor found no documentation of consent for Resident #120's bed rail use, and the Nursing Home Administrator (NHA) confirmed the absence of consent. Similarly, Resident #23 was observed with bed rails, and a review of their medical record also failed to reveal a consent form for the bed rail use. The DON reiterated the facility's process of assessment and consent documentation, but the surveyor again found no evidence of consent. The NHA confirmed that there was no consent for Resident #23's bed rail use. These findings indicate a failure by the facility to ensure that informed consent was obtained and documented prior to the use of bed rails for these residents.
Failure to Communicate Pharmacist Recommendations to Physicians
Penalty
Summary
The facility failed to ensure that pharmacists' recommendations regarding medication irregularities were communicated to the residents' physicians. This deficiency was identified during a survey for three residents who were reviewed for unnecessary medications. For Resident #51, the Director of Nursing (DON) was unable to provide the pharmacy report from November 2023, which contained potential irregularities and recommendations. The process described by the DON involved the pharmacist emailing the report to clinical management staff, who would then print and deliver it to the physician for review and signature. However, there was no documentation to confirm that the physician received or acted upon the pharmacist's recommendations. Similarly, for Resident #111, the DON could not provide the pharmacy review from October 2023, nor could she confirm whether any irregularities were addressed by the resident's physician. The same process was described, where the pharmacist's report was supposed to be reviewed and signed by the physician, but again, there was no documentation to verify that this occurred. The lack of documentation indicated a failure in the communication process between the pharmacist and the physician regarding medication irregularities. For Resident #117, the pharmacist's reports identified irregularities on three occasions, with recommendations for actions such as discontinuing duplicate medications and conducting specific tests. Although the reports were eventually provided, they were not part of the resident's medical record, and there was no documentation in the medical record to indicate that the attending physician reviewed or responded to the pharmacist's recommendations. This lack of documentation and communication highlights a systemic issue in ensuring that pharmacists' recommendations are properly addressed and documented in the residents' medical records.
Delayed Call Bell Response in LTC Facility
Penalty
Summary
The facility failed to respond timely to residents' call bells, as evidenced by a complaint involving a resident whose call bell went unanswered for 42 minutes or longer on multiple occasions. The complaint was reviewed during a recertification survey, revealing that the resident experienced delays on specific dates, with some instances occurring twice in a single day. Interviews with staff members, including a Geriatric Nursing Assistant (GNA) and a Licensed Practical Nurse (LPN), highlighted that the expectation was to answer call bells within 8 minutes, as communicated during staff meetings and orientation. However, the actual response times significantly exceeded this expectation. Further investigation revealed that the facility lacked a formal call bell policy. The Director of Nursing (DON) confirmed the absence of such a policy during an interview. The Nursing Home Administrator (NHA) and DON acknowledged the deficiency in call bell response times, confirming the delays and recognizing it as a deficiency. The report does not mention any corrective actions or follow-up measures taken to address the issue.
Failure to Protect Resident from Abuse by GNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a geriatric nursing assistant (GNA) and a resident who required assistance with transfers. The resident, who needed help moving from bed to wheelchair and back, requested assistance from GNA #15 to return to their room after lunch. The GNA refused to assist the resident, stating that she would help when she was ready, despite the resident expressing discomfort and a desire to return to their room. The GNA further dismissed the resident's request by telling them to be quiet and that they would be taken back after dinner. The resident attempted to wheel themselves back to their room, and other staff members noticed and assisted the resident. The incident was reported to the Assistant Director of Nursing the following morning. An interview with GNA #15 confirmed that she refused the resident's request for assistance and also prevented visitors from helping the resident. The Director of Nursing later substantiated the abuse, leading to the termination of the GNA.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. On January 9, 2023, a family member reported to a supervisor that the resident alleged abuse and retaliation by staff. The facility's investigation included interviews with staff members assigned to the resident during the time of the alleged abuse and some residents. However, the investigation lacked documentation of an interview with the family member who reported the allegation, the resident involved, and the supervisor who initially received the report. During a discussion on October 10, 2024, with the Director of Nurses (DON), it was revealed that these critical interviews were missing from the investigation. The DON acknowledged the concerns and expressed surprise that the interviews were not included. This oversight indicates a failure to conduct a comprehensive investigation into the abuse allegation, as essential interviews were not documented.
Failure to Notify Primary Care Provider of Lab Result
Penalty
Summary
The facility failed to notify a primary care provider of a lab result for a resident reviewed for urinary tract infections. On 9/20/24, a urine culture and sensitivity test for the resident was compromised as the specimen was spilled in transit. This incident was communicated to a Registered Nurse, identified as Staff #14. However, there was no documentation in the resident's medical record indicating that this information was communicated to the primary care provider. An interview with the Registered Nurse Care Coach/Unit Manager confirmed that it is the nurse's responsibility to review lab results and notify the primary care provider, as well as document the communication and the provider's response. The Director of Nursing was made aware of the failure to notify the provider of the lab result.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and well-repaired environment, as evidenced by several maintenance issues that were not addressed in a timely manner. On the Potomac Unit's 2nd floor, a housekeeping closet was found unlocked with a broken keypad lock, allowing access to cleaning supplies and hand sanitizers. This was confirmed by a registered nurse and the Director of Nursing, who acknowledged the deficiency. Additionally, a hole in the wall of a hallway bathroom was observed, which was stuffed with toilet paper. The Maintenance Director was unaware of the issue until it was pointed out during the survey. In two resident rooms, the drywall behind the beds was gouged, exposing the underlying surface. Despite multiple observations, the damage remained unaddressed. The Maintenance Director stated that work orders for non-emergent issues were processed through the front desk and tracked via a computer system. However, he was not aware of any work orders for the damaged drywall in these rooms and noted that repairs could not be completed while the rooms were occupied. Documentation showed previous repairs in other rooms, but no current work orders for the affected rooms were found.
Failure to Include Care Plan in Resident Transfer Documentation
Penalty
Summary
The facility failed to include the resident care plan with the required documentation during a transfer, as evidenced by the case of Resident #45, who was hospitalized on two occasions. During interviews with several Licensed Practical Nurses (LPNs), it was revealed that the nurses used a transfer checklist to ensure required documents were sent with the resident upon transfer. However, the review of the transfer form checklist did not indicate the inclusion of a care plan. Multiple LPNs confirmed that they would not send the resident's care plan upon transfer. The Director of Nursing (DON) acknowledged that the care plan should be sent with residents upon transfer, but this was not being practiced, leading to the deficiency.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of transfer to residents and their representatives, as required. This deficiency was identified for two residents who were hospitalized. For the first resident, the medical record review revealed that the resident was hospitalized on two occasions, but there was no evidence of a written transfer form being provided to the resident or their representative for these hospitalizations. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility typically did not provide written notices to residents and only verbally informed the representatives, which was not consistently documented. For the second resident, the medical record indicated a transfer to a hospital due to respiratory distress. Although there was documentation of the transfer and verbal notification to the resident's representative, there was no evidence that a written notice was provided to the resident or their representative. The NHA and DON acknowledged the deficiency, noting that while a transfer notice form was supposed to be completed and given to the resident and/or representative, it was not consistently done, and the documentation was not found in the medical records.
Failure to Prepare and Document Resident Transfers
Penalty
Summary
The facility failed to properly orient, prepare, and document the transfer of two residents to the hospital. For one resident, the medical record review revealed hospitalizations on two separate dates, but there was no documentation indicating that the resident was prepared and oriented for these transfers. The Director of Nursing (DON) confirmed that the facility used progress notes and a transfer form to document transfers, but the review of these documents did not show evidence of preparation and orientation for the resident. For another resident, the medical record indicated a transfer to an acute care facility due to respiratory distress. Although the SBAR communication documented the resident's condition and the physician's order for transfer, there was no evidence that the resident was informed about the reason for the transfer or that the resident's understanding was documented. The DON acknowledged these concerns when they were brought to her attention.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents and their representatives upon transfer to an acute care facility. This deficiency was identified during a review of medical records for two residents who were hospitalized. For one resident, the electronic medical record indicated a transfer to a hospital due to respiratory distress, but there was no documentation that the resident or their representative received written notice of the bed-hold policy at the time of transfer or within 24 hours in the case of an emergency. Interviews with the Nursing Home Administrator (NHA) and the Director of Nurses (DON) revealed that while verbal notifications were given, written notices were not consistently provided or documented in the residents' records. Similarly, for another resident who was hospitalized on two occasions, the facility failed to provide evidence of a written bed-hold policy notification. The NHA admitted that the policy notifications were not always given to residents and were not consistently uploaded into the electronic medical record, relying instead on verbal communication. Despite requests from the surveyor, the facility was unable to produce documentation of the written notifications for the resident's hospitalizations, highlighting a systemic issue in ensuring compliance with notification requirements.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive, resident-centered care plans for two residents during a recertification survey. For one resident, who was moderately cognitively impaired and had diagnoses including anxiety disorder and depression, the care plan did not include measurable goals and non-pharmaceutical interventions for managing psychosis. The resident was receiving psychotropic medications, including Quetiapine for hallucinations and psychosis, and Ativan for agitation, restlessness, and anxiety. Despite these treatments, the care plan only addressed potential complications from psychotropic drugs and lacked a comprehensive approach to the resident's condition. Another resident, who had a hearing aid, was found to have a care plan that failed to indicate the presence of the hearing aid. The Minimum Data Set (MDS) assessment had noted the hearing aid, but the care plan was not updated to reflect this information after the most recent care plan meeting. The Director of Nursing confirmed the deficiency, acknowledging that the care plan should have included the hearing aid information.
Unlicensed Feeding Assistance by Private Duty Aide
Penalty
Summary
The facility failed to ensure that only licensed staff fed residents, as observed during a recertification survey. On the 2nd floor Potomac Unit dining room, an unidentified female without a name badge was seen feeding a resident in a wheelchair, identified as Resident #39, who required feeding assistance. This individual was later identified as a private duty aide (PDA #2) hired for another resident, Resident #11. PDA #2 fed Resident #39 multiple times, leaving and returning to the table, while other facility staff were present in the dining area and hallways. Interviews conducted with a Geriatric Nursing Assistant (GNA #3) and the unit manager, a Registered Nurse (RN #1), confirmed that PDA #2 was not licensed and should not have fed Resident #39. The Director of Nursing (DON) explained that PDA #2 had been working with Resident #11 for over a year and was asked by Resident #11 to assist Resident #39. Despite the presence of other GNA staff who observed the incident, no intervention occurred. The DON acknowledged the deficiency and stated that PDA #2 should have informed the nurse or assigned GNA about Resident #39's need for assistance.
Inadequate Parameters for As-Needed Constipation Medications
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary medications by not providing adequate parameters for administering as-needed medications for constipation. During a review of the medical record for a resident, it was found that the September Medication Administration Record (MAR) included three medications prescribed as needed for constipation, with no clear guidelines on which medication to administer first. Two of these orders were for the same medication, Polyethylene Glycol Powder. The orders included lactulose oral solution to be taken every 12 hours as needed, Miralax Powder to be taken once a day as needed for no bowel movement, and Polyethylene Glycol Powder to be taken every 24 hours as needed. The lack of clear instructions in the physician orders led to confusion about which medication should be administered first for constipation relief. This issue was discussed with the Director of Nurses, who acknowledged the concern.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication by not adequately monitoring the resident for behavior, side effects, or adverse consequences related to psychotropic medication use. This deficiency was identified for one resident who was admitted to the facility following an acute hospitalization. The resident had moderate cognitive impairment, medically complex conditions, and multiple medical diagnoses, including dementia, anxiety disorder, and depression. The resident was prescribed an antipsychotic and an antidepressant, and received antipsychotics on a routine basis. The medical record review revealed that the resident was prescribed Duloxetine for depression, Quetiapine for hallucination and later for psychoses, and Lorazepam for restlessness, agitation, and anxiety. Despite orders to monitor the resident's behavior for agitation and mood decline, the facility failed to document specific behaviors or individualized, non-pharmacological approaches to care. Additionally, there was no documentation indicating that the resident was monitored for the specific behaviors for which the antipsychotic Seroquel had been prescribed. The Director of Nurses acknowledged these concerns during a discussion with surveyors.
Improper Food Storage Leading to Cross-Contamination Risk
Penalty
Summary
The facility failed to properly store food items to prevent cross-contamination, as observed during a survey. On one occasion, a surveyor found a sausage wrapped in plastic without a label or date in the walk-in freezer, which was subsequently removed by the Dining Services Supervisor. In another instance, a surveyor observed two metal containers in the second-floor kitchen of the Maryland unit. One container held red sauce, identified as salsa, without a cover or label, and the other contained an open bag of sour cream with a serving scoop inside. A dining server identified the items and removed them for disposal after being shown by the surveyor. The Dining Director acknowledged that the items should not have been left uncovered and unlabeled in the refrigerator.
Failure to Void Outdated MOLST Forms
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records by not voiding outdated Maryland Orders for Life Sustaining Treatment (MOLST) forms when new ones were created for residents. This deficiency was identified during a review of medical records for three residents, where it was found that each resident had multiple active MOLST forms with conflicting orders. For instance, one resident had an active MOLST form in their electronic medical record (EMR) indicating 'No CPR, Option B,' while their hard chart contained a different active MOLST form with 'No CPR, Option A-2.' Similar discrepancies were found in the records of the other two residents. The issue was brought to light during a survey when the surveyor requested copies of the active MOLST forms. The Nursing Home Administrator (NHA) acknowledged the concern and indicated that the MOLST forms were intended to be kept only in the paper chart, not in the EMR. The failure to void previous MOLST forms when new ones were created led to the presence of multiple active forms with conflicting orders in the residents' medical records.
Infection Control Deficiency: Foley Catheter Bag on Floor
Penalty
Summary
The facility failed to use appropriate infection control practices for a resident with an indwelling Foley catheter. During an observation, the surveyor noted that the resident's Foley catheter bag was lying flat on the floor. This observation was confirmed by a nurse, who acknowledged that the catheter bag should not be in contact with the floor. The nurse then adjusted the bed to ensure the catheter was no longer touching the floor, indicating that the bed had likely been lowered to its lowest position, causing the catheter bag to rest on the floor.
Failure to Educate on Pneumonia Vaccination Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents or their representatives were educated on the risks and benefits of pneumonia vaccinations. This deficiency was identified during a survey for two residents. For one resident, the immunization record indicated a refusal of consent for vaccines, but there was no documentation showing that the resident or their representative was informed about the health benefits and risks of receiving vaccinations. Similarly, another resident's representative refused a pneumococcal vaccination, yet there was no evidence of education provided regarding the risks and benefits of the vaccination. The Infection Preventionist nurse confirmed the lack of documentation for educational efforts in these cases.
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.
