Turtle Creek Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kensington, Maryland.
- Location
- 3000 Mccomas Avenue, Kensington, Maryland 20895
- CMS Provider Number
- 215043
- Inspections on file
- 17
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Turtle Creek Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
The facility failed to keep a resident’s care plan consistent with the most recent MOLST, resulting in conflicting documentation where the MOLST indicated full code while the care plan and active orders still showed DNR, and the assigned nurse stated she would follow the outdated DNR status. In addition, the facility did not hold required interdisciplinary care plan meetings within the mandated timeframe after MDS assessments for two residents, with no care conference notes documented following those assessments and a social worker operating under an incorrect understanding of the timing requirements and the need for a guardian’s presence.
A resident who considered group activities and going outside for fresh air to be very important had a care plan directing staff to encourage participation in group, entertainment, religious, and outdoor activities and to invite the resident to scheduled programs. Observations showed the resident in their room watching TV, and a complaint alleged the resident was receiving less attention than others. Review of activity and medical records for multiple months showed no documentation that group or outdoor activities were provided, attended, or refused, despite the Activity Director stating that such activities occur daily and refusals are documented.
The facility failed to prevent multiple known smokers from smoking in their rooms and hallways despite documented non-compliance, behavioral issues, and prior staff observations. One resident with psychosis and a history of non-compliance was repeatedly seen smoking in a room and hallway and later refused assessment after smoke was found coming from the mattress. Another resident with tobacco use was documented picking cigarette butts from the trash, smoking in rooms, bathroom, and hallway, and verbally refusing to stop despite repeated redirection. A third resident with tobacco use and multiple psychiatric diagnoses was observed smoking in the room. Staff reported residents blocking doors while holding lit cigarettes, aggressive behavior when staff attempted to confiscate smoking materials, and at least one instance where observed in-room smoking was not reported. Leadership acknowledged that residents were not supposed to have smoking materials in their rooms and that cigarettes and lighters were to be stored and dispensed at designated smoking times, yet residents continued to obtain and keep smoking materials in their rooms, leading to a room fire.
Surveyors found that not all staff had received mandatory QAPI training. During review of five randomly selected employee education files, one staff member hired several months earlier had no documented QAPI training. The Administrator confirmed there was no evidence that this staff member had completed the required QAPI education.
Surveyors found that the facility did not ensure all staff received required annual Compliance and Ethics training. Review of five randomly selected employee education files showed that one employee hired more than a year earlier had no documented Compliance and Ethics training during the review period. The administrator confirmed there was no evidence that this staff member had completed the mandatory annual training.
Surveyors found that a nurse aide hired in mid-2024 had no documented completion of the required 12 hours of annual in‑service training, including dementia management and abuse prevention, during the review period. Education records for several nurse aides were examined, and one aide’s file lacked any evidence of the mandated training hours. The Administrator confirmed that there was no documentation showing this aide had received the required education.
Surveyors found that staff did not consistently label or date food items in the kitchen and nourishment rooms, with multiple instances of undated canned goods, improperly stored leftovers, and open or unlabeled bags of food in refrigerators and freezers. Dietary and nursing staff acknowledged these lapses, and employee food was also found stored in resident refrigerators.
Surveyors found that multiple resident bathrooms lacked blinds, curtains, or frosted windows, resulting in inadequate privacy. A family member raised concerns, and surveyors confirmed that bathrooms were visible from outside. The MD was unaware of any window coverings ever being used, and the DON acknowledged the issue.
Surveyors observed that linen carts contained only minimal towels and washcloths, and staff reported frequently needing to retrieve additional linens from the laundry due to ongoing shortages. Laundry staff confirmed a lack of sufficient towels, washcloths, and gowns, and the Regional Environmental Director stated that the facility's linen supply was below the expected standard.
A resident alleged physical abuse by a GNA, and although an investigation was initiated, the accused staff member continued to work regular shifts with residents during the investigation. Facility policy required suspension of accused staff pending investigation, but review of personnel records and timecards confirmed no suspension was issued.
A resident's right to self-determination was not honored when staff deferred to a health care proxy for consent without documented evidence of incapacity, despite the resident's ability to communicate and a MOLST form indicating their wishes. The DON was unable to provide prior documentation of incapacity, and only produced an evaluation after the issue was raised.
A resident's preference for female healthcare providers was not documented in the care plan, despite staff and management being aware of the request. The omission was confirmed through interviews with the resident, staff, and the DON, as well as a review of the medical record.
Facility staff did not update a resident's MOLST form after a court-appointed legal guardian was established, leaving the outdated form listing the resident as the decision maker. The oversight was discovered when staff reviewed the record and found both the old MOLST and the court order in the file, with the DON confirming the error.
Facility staff did not document ongoing re-assessments or attempts at less restrictive alternatives for a resident using a half gate as a physical restraint. The resident, who had cognitive and safety awareness deficits, had a care plan requiring regular evaluation of restraint use, but only a single quarterly assessment was provided, with no evidence of continued re-evaluation as required by facility policy.
A resident was discharged home, as confirmed by both the medical record and discharge summary, but the MDS assessment incorrectly documented the discharge as being to a short-term general hospital. The MDS Coordinator acknowledged the error during an interview.
Surveyors found that two residents did not receive wound care treatments in accordance with current orders and wound team recommendations. In both cases, discrepancies existed between the wound NP's documented recommendations and the treatments recorded on the TAR, including outdated or incorrect wound care products and frequencies. The DON confirmed that changes in nursing staff responsible for wound care orders contributed to these inconsistencies.
The facility did not maintain adequate nursing staff on weekends, leading to delayed or unanswered call lights as reported by multiple residents. Staffing records showed that nursing hours per patient day were consistently below required levels on weekends, and the DON confirmed that staff call-outs could not always be replaced during these times.
A resident did not receive multiple doses of their prescribed Pregabalin for neuropathic pain because the medication was not available or was awaiting pharmacy delivery. Medication Administration Records and progress notes confirmed several missed doses, and the DON acknowledged that the medication should have been available.
Surveyors found that two residents' medication regimen reviews identified by the consulting pharmacist were not addressed or documented by the provider in a timely manner. In both cases, recommendations for medication order changes or laboratory monitoring were delayed, and there was no clear documentation in the medical record showing that the provider reviewed or responded to the pharmacist's recommendations.
A medication pass observation revealed that an LPN administered discontinued medications and incorrect dosages to two residents, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of less than 5%.
Surveyors found that two residents received medications that had been discontinued, with the discontinued drugs still stored in the medication cart. Additionally, a resident's Methadone medication was missing an expiration date on its label, and this information was not documented elsewhere. Staff confirmed these deficiencies in medication storage and labeling.
The facility did not properly maintain the outdoor garbage storage area, as four mattresses and other materials were left piled next to the dumpsters used by the kitchen. The Maintenance Director confirmed the presence of potential vermin habitats nearby and stated that the mattresses had not been disposed of in the dumpster because the garbage removal company would not take them.
A resident's medical record contained an error in PASARR documentation, where a Level I screen was marked as positive for SMI, indicating a need for Level II screening, despite only two of three required questions being marked 'yes.' The DON was unsure about the requirement and deferred to the Social Worker, who later confirmed the positive result was marked in error. This resulted in incomplete and inaccurate medical recordkeeping.
Surveyors found that the facility failed to maintain a clean, comfortable, and homelike environment, with an exterior kitchen door showing an unrepaired opening, crumbling drywall and water stains in two resident rooms, and a protruding nail in a resident shower room. The Maintenance Director and DON acknowledged these maintenance concerns during interviews.
A resident with a history of hemiplegia and muscle contractures was injured when a GNA ignored their request not to be repositioned in bed, resulting in a fractured finger. Despite initial x-rays showing no fracture, further evaluation confirmed the injury. The GNA, who had a history of conduct issues, was terminated following the incident.
The facility did not employ a full-time licensed social worker despite having 140 certified beds, leading to unresolved issues for residents. Complaints revealed a lack of communication and coordination in care plans and discharge processes after the previous social worker left. The social work assistant, who was not licensed, was overwhelmed and handling all residents alone. Attempts to recruit a licensed social worker were unsuccessful, and supervision was provided by a corporate staff member not present full-time.
Facility staff failed to maintain a sanitary and comfortable environment, with deficiencies observed in resident rooms and common areas. Issues included unsanitary conditions, disrepair of furniture and fixtures, and lack of essential supplies. A corporate nurse acknowledged the concerns, including mold presence.
The facility failed to report allegations of abuse to the OHCQ within the required 2-hour timeframe for five incidents. These included cases where residents reported being hit, spit on, or experiencing pain due to staff actions. The facility's investigations lacked email confirmations of report submissions, and interviews with the DON revealed a failure to maintain proper documentation.
The facility failed to conduct quarterly care plan meetings for several residents, as required. This deficiency was identified during a complaint survey, where it was found that seven residents did not have their care plans reviewed and revised quarterly. The lack of meetings was confirmed through interviews with the DON and review of medical records. Additionally, responsible parties reported communication issues and difficulties in coordinating discharge plans due to the absence of care plan meetings.
The facility failed to administer medications as ordered for several residents, including Methadone for a resident with opioid dependence and Midodrine for a resident with hypotension. Additionally, a resident with dry eye syndrome did not receive timely treatment, and another resident's risk for elopement was inaccurately assessed.
A resident with a Stage III sacral pressure ulcer was not reassessed weekly by the facility staff, as required. The Wound Nurse Practitioner initially assessed the wound and documented its measurements, but the staff failed to reassess the wound on a specified date. The resident was later discharged to the hospital. The DON confirmed the failure to reassess the wound.
Facility staff were observed pulling two residents backwards down hallways, compromising their dignity. An LPN pulled a resident from the dining room to their room, while a GNA moved another resident to an activity room without knowing their name. These actions were confirmed as dignity issues by a staff member.
Facility staff failed to notify a resident's physician of a low blood pressure reading of 73/49 mmHg. Despite the critical nature of this reading, there was no documentation of physician notification. The DON confirmed that the physician should have been informed, but the medical record lacked evidence of such communication.
A facility failed to provide a baseline care plan to a resident and their representative within 48 hours of admission, as required. This plan should include initial goals, physician orders, therapy, dietary, and social services. A review found no evidence of the plan being provided, and a Regional Nurse confirmed the oversight, indicating a lapse in communication and documentation.
Facility staff did not include a resident's risk of elopement in their care plan, despite the resident leaving the facility unaccompanied and being found attempting to exit again. The DON confirmed the absence of a care plan addressing this risk.
A facility failed to develop and update a discharge plan for a resident admitted for rehabilitation after an accident. The resident's responsible party had been trying to facilitate a return home since early in the year, but faced difficulties due to staff changes and lack of action. The social work assistant conducted a care plan meeting but did not document it, and the DON and NHA were unaware of the issue until informed by the Ombudsman.
A facility failed to provide proper colostomy care for a resident with a malignant neoplasm. The resident's colostomy care orders were discontinued without explanation, and the family had to purchase colostomy bags themselves. The bags were improperly secured, leading to leakage. The facility's colostomy supplies required clips, but one bag was found stapled shut. The DON was informed, but no response was given.
The facility failed to maintain access to closed medical records and ensure the accuracy of electronic records. A resident's closed record was unavailable, and another's electronic record inaccurately documented a consultation after the resident had left the facility. Additionally, vital signs were recorded for a discharged resident, and a third resident's record was missing, preventing verification of personal belongings.
Failure to Update Code Status in Care Plan and Hold Timely Interdisciplinary Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s care plan to reflect the most current Medical Orders for Life-Sustaining Treatment (MOLST). For one resident, the most recent MOLST form indicated that cardiopulmonary resuscitation (CPR) should be attempted in the event of cardiac or pulmonary arrest, meaning the resident was full code and had capacity to make medical decisions. However, the resident’s care plan, initiated and later revised on prior dates, continued to list the resident’s code status as do not resuscitate (DNR) and referenced the MOLST as the basis for that status. The active medical orders in the record also showed a DNR order, creating conflicting documentation between the MOLST and the care plan/medical orders. When interviewed, the nurse assigned to the resident confirmed there was conflicting information regarding the code status and stated that, if the resident’s heart stopped, she would not provide CPR, basing her decision on the current care plan and medical orders that indicated DNR. A nurse practitioner later confirmed that the resident was actually full code and that the resident had decision-making capacity, and also confirmed the presence of conflicting code status information in the record. A social worker’s note documented that a care plan meeting had been held and that the code status was reviewed and indicated as DNR, but the care plan itself still reflected DNR status even after the MOLST had been changed to full code. The deficiency also includes the facility’s failure to ensure that interdisciplinary care plan meetings were held within the required timeframe following completion of Minimum Data Set (MDS) assessments. For one resident, an MDS assessment was completed, but there was no care conference note indicating that a care plan meeting occurred after that assessment. For another resident, a quarterly MDS assessment was completed, but the last documented care conference note predated that assessment, and no subsequent care plan meeting was documented. The social worker reported that care plan meetings were held on specific weekdays and believed she had a window of seven days before or after the assessment reference date to hold the meeting, and she also stated she was trying to schedule a meeting with the resident’s guardian and believed the guardian needed to be present. Review of the record showed only a progress note about a behavior concern, with no indication that a care plan meeting occurred or that the care plan was reviewed or discussed following the MDS assessment.
Failure to Provide and Document Care-Planned Group and Outdoor Activities
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision and documentation of activities based on a resident’s comprehensive assessment and care plan. Record review of the resident’s most recent comprehensive assessment (reference date 7/15/25, Section F) showed it was very important to the resident to participate in group activities and to go outside for fresh air when the weather was good. The resident’s activity care plan included interventions such as encouraging attendance at entertainment programs, large and small group activities, volunteer demonstrations, religious activities, and inviting the resident to scheduled activities. During observations on two separate dates, the resident was seen in their room watching TV, and there was a complaint allegation that staff were mistreating the resident by showing other residents more attention. A review of the April 2026 activity calendar and participation records on 4/17/26 did not show any documentation that the resident attended group or outdoor activities, nor that such activities were offered and refused. The Activity Director stated that the resident usually preferred independent activities in their room and reported that refusals are documented and that group activities occur daily. However, when the Activity Director reviewed the resident’s medical record with the surveyor, he confirmed there was no documentation for March or April 2026 indicating that the resident had attended or refused group and/or outdoor activities. This lack of documentation and evidence of implementation of the care-planned activities formed the basis of the deficiency.
Failure to Control Resident Smoking in Rooms Resulting in Fire
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective system to prevent residents from smoking in their rooms, which resulted in a fire in a resident room. One resident with diagnoses including unspecified psychosis and non-compliance with medication was documented on a change in condition note as being observed continuously smoking in the room and hallway, refusing redirection and continuing to smoke in the room shared with another resident. A subsequent behavior note indicated this same resident refused a head-to-toe assessment three times after the fire marshal noted smoke coming from the resident’s mattress. Staff interviews confirmed that this resident had been seen smoking in the room on multiple occasions in the week prior to the fire. Another resident, admitted with a diagnosis including tobacco use, was documented in multiple change in condition notes as picking cigarette butts from the trash on the smoke porch and being observed smoking multiple times in the room, bathroom, another resident’s room, and the hallway. This resident was repeatedly redirected but refused to comply, stating they had the right to smoke anywhere and did not care about the adverse effects of smoke on non-smokers. Nursing documentation also noted that this resident continued to smoke in the room, cursed at staff when confronted, and would not yield to teaching. Staff interviews corroborated that this resident had been seen smoking in the room in the week prior to the fire and that attempts to obtain smoking materials were met with aggression and refusal. A third resident, with diagnoses including tobacco use, intermittent explosive disorder, opioid abuse, bipolar disorder, and generalized anxiety disorder, was documented in a nursing note as being observed smoking in the room and receiving education about the danger of such behavior. Despite a facility policy that residents could not have smoking materials in their rooms and that smoking materials were to be stored on a cart and obtained from social services or nursing at designated times, staff interviews revealed that residents were still able to obtain and keep smoking materials. One staff member reported seeing two residents with lit cigarettes in the hallway who then went into a room and blocked the door, and another staff member reported finding a resident smoking in the room on two separate occasions, once without reporting it because no one was present at the nurses’ station. After the fire, a resident previously known to smoke in the room was observed with two cigarette lighters on the bedside table, confirmed by the nurse, indicating ongoing access to smoking materials in resident rooms. Interviews with the ADON, DON, and social worker showed that facility leadership was aware that some residents were non-compliant smokers and that residents with known behaviors of smoking in their rooms existed prior to the fire. The ADON acknowledged that residents were supposed to have their cigarettes and lighters stored on a cart and be supervised on the smoke porch, but stated that some residents did not follow the rules and that the facility used behavioral contracts and medical/psych consults when residents did not comply. The DON stated that residents sometimes secretly brought smoking materials into the building and that no one knew how the resident involved in the fire obtained them. The social worker confirmed that certain residents had known behaviors of smoking in their rooms and that no residents were supposed to have smoking materials in their rooms. Observation of the unit showed posted smoking schedules that left a long period with no scheduled smoking times, while multiple residents with tobacco use and behavioral issues continued to smoke in their rooms and hallways despite staff awareness and prior documentation, culminating in a fire in a resident room.
Removal Plan
- Review the facility smoking policy with all identified smoking residents.
- Ask all residents to turn in all smoking materials.
- Visually inspect all resident rooms for smoking materials.
- Place any collected smoking materials in the smoker's box.
- Assign Residents #1, #2, and #3 to one-on-one supervision due to refusal to turn in smoking materials.
- Maintain one-on-one supervision for Residents #1, #2, and #3 until they no longer have smoking materials in their possession and demonstrate no behaviors of smoking in their rooms.
- Educate all staff that residents may not have any smoking materials on them.
- Educate all staff that residents may only smoke at designated smoking times in the designated area.
- Educate all staff that if they become aware of a resident smoking in their room or having smoking materials on them, they are to ask the resident for the materials.
- Require that if a resident refuses to turn in smoking materials, the resident is placed on one-on-one supervision immediately and the staff member notifies the Executive Director or nursing supervisor.
- Audit nursing notes of identified residents who smoke in the daily clinical meeting for documentation of illegal smoking activity.
- Inspect the room of each resident identified as a smoker for smoking materials or evidence of smoking in the room.
- Have the Executive Director audit all Ambassador round reports for residents identified as smokers.
- Have the Director of Nursing audit all nurses' notes to evaluate whether violations of the smoking policy have been discovered.
- Submit audit results to the Quality Assurance and Performance Improvement Committee for review and approval.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory Quality Assurance and Performance Improvement (QAPI) training. During a complaint survey, surveyors reviewed QAPI education records for five randomly selected employees on 2/9/26. One employee, identified as Staff #20, hired on 7/31/24, had no documented completion of QAPI training in their education records. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this staff member had received the required QAPI training.
Failure to Provide Mandatory Annual Compliance and Ethics Training to All Staff
Penalty
Summary
The facility failed to ensure that all staff received mandatory annual Compliance and Ethics training, as evidenced by the education record of one employee. During a complaint survey, surveyors reviewed education records for five randomly selected employees for the period from January 2025 through February 2026. For Staff #20, who was hired on 7/31/24, there was no documentation showing completion of Compliance and Ethics training during that review period. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this staff member had received the required annual Compliance and Ethics training. This deficiency was identified for 1 of 5 employees whose records were reviewed for compliance with the facility’s mandatory Compliance and Ethics education requirements.
Failure to Provide Required Annual Training in Dementia Management and Abuse Prevention
Penalty
Summary
The facility failed to ensure that a nurse aide received the required 12 hours of annual training that included dementia management and abuse prevention. During a complaint survey, surveyors reviewed education records for five randomly selected nurse aides on 2/9/26. For one nurse aide hired on 7/31/24 (Staff #20), review of education records from January 2025 through February 2026 showed no evidence that this staff member had completed 12 hours of training, nor that the training included dementia management and abuse prevention. In an interview on 2/9/26 at 2:13 PM, the Administrator confirmed there was no evidence that this nurse aide had received the required annual training during that period.
Improper Food Storage and Labeling in Kitchen and Nourishment Rooms
Penalty
Summary
Facility staff failed to properly store food in accordance with professional standards for food service and safety, as observed during kitchen and nourishment room inspections. In the kitchen's dry storage, several canned goods, including sliced peaches and mandarin oranges, were found without received or expiration dates. Containers of flour were also missing dates, and some items in the kitchen cooler, such as cut pineapple and what appeared to be butter and sausage patties, were either past their use-by dates or lacked proper labeling and dating. In the kitchen freezer, multiple opened bags of food items, including cheese omelets, turkey patties, breaded chicken portions, croissants, and Italian steak rolls, were found without labels or dates indicating when they were opened, and some were left open to air. In the nourishment rooms on both the first and second floors, food items in resident refrigerators were found without proper labeling or dating. Items included a water bottle with an unknown yellow substance, bags of food labeled only with room numbers and missing dates, and takeout containers with outdated labels. Additionally, employee food was found stored in resident refrigerators, which is not permitted. These deficiencies were confirmed through interviews with dietary and nursing staff, who acknowledged the lack of compliance with labeling, dating, and storage protocols.
Inadequate Privacy in Resident Bathrooms Due to Uncovered Windows
Penalty
Summary
Surveyors identified a deficiency related to inadequate privacy in resident bathrooms throughout the facility. During interviews and observations, it was noted that multiple resident bathrooms on the ground floor lacked blinds or curtains on the windows, and the windows were not frosted, allowing visibility from outside. Brackets for blinds or curtains were present but not in use. A family member of a resident expressed concerns about bathroom privacy, and during an exterior tour, surveyors confirmed that the interiors of these bathrooms were visible from outside. The Maintenance Director stated he was unaware of any blinds or curtains ever being used in these bathrooms, and the DON acknowledged the privacy concerns.
Inadequate Linen Supply for Resident Care
Penalty
Summary
The facility failed to provide an adequate supply of linens, including towels and washcloths, for residents. During multiple observations, surveyors noted that linen carts in the hallways contained only one or two towels and washcloths. Geriatric Nursing Assistants reported that while they could provide care, they often needed to go to the laundry to obtain additional linens. Laundry staff confirmed a persistent shortage of laundry items, particularly washcloths, towels, and gowns, and stated that there was not enough laundry available when staff requested it. The Regional Environmental Director acknowledged that the facility's linen supply was below the expected Periodic Automatic Replacement (PAR) level, which is set at three linen changes per resident per day, and that the facility was currently well below this standard.
Failure to Suspend Accused Staff During Abuse Investigation
Penalty
Summary
The facility failed to prevent further potential abuse during an active investigation of alleged staff-to-resident abuse. On 2/18/21, a resident reported to county police that a Geriatric Nursing Assistant (GNA) had punched them in the face four times. The facility initiated an investigation on the same day and ultimately concluded the allegation as not verified. However, during the investigation period, the accused staff member continued to work regular shifts with residents. A review of the facility's abuse prevention policy revealed that accused staff members are to be suspended pending the outcome of an abuse investigation. Examination of the staff member's personnel file and timecard confirmed that no suspension was issued and the staff member worked multiple shifts during the investigation. The Director of Nursing acknowledged that it was not acceptable for the accused staff member to continue working with residents during the investigation.
Failure to Honor Resident's Right to Self-Determination Due to Lack of Capacity Documentation
Penalty
Summary
The facility failed to honor a resident's right to self-determination and decision-making regarding their care. A review of the resident's medical record showed that the resident had a Maryland Order for Life Sustaining Treatment (MOLST) form indicating a personal decision to receive CPR in the event of cardiac arrest. Despite being non-verbal, the resident was able to communicate effectively through text and demonstrated cognitive ability through written communication. However, a social history assessment documented that the resident did not have decision-making capacity and named a health care proxy, and a nurse practitioner obtained consent for procedures from the resident's Power of Attorney without documented evidence that the resident was incapable of making their own decisions. Further investigation revealed that there was no documentation in the medical record to support that the resident was not their own decision maker at the time consent was obtained from the proxy. When asked, the Director of Nursing was unable to produce prior documentation of incapacity and only provided a current evaluation after the surveyor's request. This sequence of events indicated that the resident's right to make their own decisions was not properly recognized or honored, as appropriate evaluations to determine decision-making capacity were not in place prior to deferring to a health care proxy.
Failure to Document and Honor Resident's Provider Gender Preference
Penalty
Summary
The facility failed to update the care plan to reflect a resident's preference for female healthcare providers. During an interview, the resident reported that their preference for female providers was not honored. A review of the resident's medical record did not show any documentation of this preference. Staff confirmed that the resident had requested only female healthcare providers and that both staff and management were aware of this preference. The Director of Nursing also acknowledged that the care plan was not updated to include the resident's stated preference.
Failure to Update MOLST After Guardian Appointment
Penalty
Summary
Facility staff failed to ensure the accuracy of a Medical Orders for Life-Sustaining Treatment (MOLST) order for one resident. The MOLST form in the resident's record was from 2020 and listed the resident as the decision maker for medical treatments. However, a legal court order appointing a guardian for the resident was issued in June 2022, making the resident no longer the authorized decision maker. Despite the presence of the court order in the medical file, the MOLST was not updated to reflect the new legal guardian as the decision maker. Interviews with facility staff revealed that the unit manager had not reviewed the resident's record and was unaware of the discrepancy until it was brought to her attention. The Director of Nursing acknowledged that staff failed to incorporate the court-appointed legal guardian order and did not update the MOLST accordingly. This oversight resulted in the resident's MOLST not accurately reflecting the current legal authority for medical decision-making.
Failure to Document Ongoing Re-Assessment of Physical Restraint Use
Penalty
Summary
Facility staff failed to document ongoing re-assessments to determine the necessity of a physical restraint for a resident who utilized a half gate across their doorway. The resident, who had a history of anoxic brain damage, aphasia, attention and concentration deficits, lack of awareness of boundaries, and poor safety awareness, was observed interacting with the gate and moving about their room. The resident's care plan included the use of the half gate restraint to prevent entry into other rooms and to maintain safety, with interventions specifying quarterly and as-needed evaluations of restraint use, as well as documentation of continued risk, benefits, and reasons for restraint use. Upon review, the surveyor found that the facility's policy required documentation of medical symptoms warranting restraint use, attempts at less restrictive alternatives, and ongoing re-evaluation of the restraint's necessity and effectiveness. However, the facility was unable to provide evidence of ongoing re-evaluation or documentation of less restrictive interventions for the resident. The only documentation provided was a quarterly assessment, and no further records were produced upon request.
Inaccurate Coding of Resident Discharge Status on MDS Assessment
Penalty
Summary
The facility failed to accurately code a resident's discharge status on the Minimum Data Set (MDS) assessment. Medical record review showed that the resident had an order to be discharged home and a discharge summary confirming discharge to home. However, the MDS assessment documented the resident as being discharged to a short-term general hospital. During an interview, the MDS Coordinator confirmed that the MDS was inaccurately completed, as the resident was actually discharged home.
Failure to Follow Wound Care Orders and Recommendations
Penalty
Summary
The facility failed to provide wound care treatments in accordance with the residents' current plans of care and the recommendations of the wound care team. For one resident, there were discrepancies in the treatment orders for a left buttock wound, where both an outdated Medihoney treatment and a new calcium alginate treatment were documented as being performed on the same day, despite the older order not being discontinued. Additionally, the treatment for a right upper arm skin tear was not updated to reflect the wound nurse practitioner's recommendation for a different frequency. The wound nurse practitioner’s notes did not support the use of Medihoney or the daily frequency for the right arm wound, yet these treatments were still being documented as completed. For another resident, the treatment administration record did not match the wound nurse practitioner's recommendations for a right knee skin tear. The practitioner's notes consistently recommended cleansing with normal saline, applying Hydrogel, and securing with an ABD pad and rolled gauze, but the order in the record specified cleansing with soap and water and using border gauze instead. The discrepancies were identified during interviews and record reviews, with the DON confirming that the nurse responsible for wound care orders was on leave and that other nurses were taking over the responsibility, leading to inconsistencies between the wound team's recommendations and the treatments being administered and documented.
Insufficient Weekend Nursing Staff Resulting in Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff on weekends to meet the needs of all residents, as evidenced by staffing records and resident interviews. Residents reported that staff were either not answering or were late in answering call lights on weekends. Staffing reports reviewed for the period from late December to early February showed that weekend nursing hours per patient day (HPPD) consistently fell below 3.0, with several specific dates documented where required hours were not met. This shortfall in staffing was directly linked to the inability to replace staff who called out on weekends. The Director of Nursing (DoN) confirmed that staffing was managed by an external agency during weekday business hours, while facility administration handled after-hours and weekend staffing. The DoN acknowledged that, despite efforts, the facility was unable to replace staff for weekend call-outs, resulting in insufficient staffing levels. The deficiency was substantiated by both resident complaints and documented staffing shortfalls.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for one resident. The resident reported not receiving their prescribed Pregabalin, a medication for neuropathic pain, on multiple occasions. Review of the Medication Administration Records for November 2024, December 2024, and January 2025 showed several missed doses, which were coded as 'other/see progress notes' or 'held/see progress notes.' Further examination of the progress notes revealed that in five instances, the medication was not available or was awaiting delivery from the pharmacy. The Director of Nursing confirmed that the resident should not have experienced unavailability of their medication.
Failure to Timely Address and Document Pharmacist Medication Irregularity Recommendations
Penalty
Summary
The facility failed to ensure timely action and proper documentation regarding pharmacist-identified medication regimen irregularities for two residents. For one resident, pharmacy reviews identified irregularities on two occasions, recommending changes to medication orders. However, the Director of Nursing (DON) did not receive these recommendations until nearly a month after the first irregularity was identified, despite the resident being seen by the attending physician multiple times in the interim. The physician did not document any review or action taken regarding the pharmacist's recommendations in the resident's medical record until the recommendations were finally addressed, well after the identified irregularities. For another resident, the pharmacist recommended a laboratory test for a medication level, but there was no documentation that the provider reviewed or acted on this recommendation during the next visit. The laboratory order was not placed until a week after the provider had seen the resident, and there was no documentation in the progress notes acknowledging the pharmacist's recommendation. The lack of timely action and documentation made it difficult to determine when the provider was notified of the recommendations and whether they were addressed appropriately.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during a medication administration observation, resulting in a 12% error rate. Specifically, a Licensed Practical Nurse (LPN) administered 1 tablet of Ibuprofen 600mg and 2 tablets of Tizanidine 4mg to a resident, despite the Ibuprofen order having been discontinued several days prior and the correct Tizanidine dose being 6mg, not 8mg as given. Additionally, the same LPN administered Vitron C to another resident after the order for this supplement had also been discontinued. These errors were confirmed through medical record review and staff interview.
Improper Storage and Labeling of Medications
Penalty
Summary
Surveyors identified that medications were not properly stored and labeled in the facility. During medication administration, an LPN was observed administering Ibuprofen 600mg to one resident and Vitron C to another, despite both medications having been discontinued according to the residents' medical records. The discontinued medications were found stored in the medication cart, and the LPN confirmed their presence. The Assistant Director of Nursing also acknowledged that discontinued medications should not be kept in the medication carts. Additionally, during a medication storage observation, a resident's Methadone medication was found without an expiration date on its label. Staff confirmed the absence of the expiration date, and a review of the methadone log form also failed to show this information. These findings demonstrate that the facility did not ensure all drugs and biologicals were properly labeled and stored according to accepted professional standards.
Improper Disposal of Garbage and Refuse Near Dumpster
Penalty
Summary
The facility failed to maintain the outdoor garbage storage area in a manner that would prevent the harboring of pests. During a tour of the outdoor dumpster used by the kitchen, four mattresses were observed piled next to the dumpsters, along with other materials surrounding them. The Maintenance Director confirmed that the wooded area near the building was a habitat for various types of vermin and acknowledged that the mattresses had been left outside because the garbage removal company would not take them. The Maintenance Director was unable to state how long the mattresses had been there and confirmed that the items had not been placed in the dumpster.
Incomplete and Inaccurate PASARR Documentation for a Resident
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards by not ensuring complete and accurate documentation for one resident. Specifically, a review of the resident's medical record revealed that a Level I Preadmission Screening and Resident Review (PASARR) evaluation was completed, with a positive response documented in the Severe Mental Illness (SMI) section, which would require a Level II screening. However, only two out of three required questions were marked as 'yes,' and the instructions indicated that all three questions must be marked 'yes' for a positive result. During interviews, the DON indicated uncertainty about whether the resident required a Level II screening and deferred to the Social Worker. The Social Service Assistant later clarified that the need for Level II screening was marked in error and that the resident did not actually require it. This discrepancy demonstrates a failure to maintain accurate and complete medical records as required by professional standards.
Deficient Maintenance of Facility Environment in Kitchen and Resident Areas
Penalty
Summary
Surveyors identified deficiencies in the facility's maintenance of a clean, comfortable, and homelike environment in both the kitchen and resident areas. Specifically, an exterior door used by kitchen staff to access the garbage disposal area was found to have an opening at the junction of the wall and the right corner of the door, allowing light from outside to enter. The Director of Maintenance acknowledged that the area had previously been repaired with concrete, but the repair had failed due to rough handling of the door, resulting in the open area reappearing. Additional deficiencies were observed in two resident rooms and a resident shower room. In one resident room, surveyors noted crumbling drywall in the bathroom window, multiple repair patches and water stains on the ceiling tile, and extensive scratches on the wall next to one of the beds. In the shower room across from the resident room, a nail was found protruding from the wall between two shower stalls, approximately 12 inches off the ground. The Maintenance Director confirmed that staff are expected to report such issues via maintenance logs or direct communication, and the DON acknowledged the maintenance concerns during interviews.
Failure to Honor Resident's Wishes Leads to Injury
Penalty
Summary
The facility failed to honor a resident's wishes regarding bed mobility, leading to an incident where a staff member caused harm to the resident. The resident, who had a history of hemiplegia, hemiparesis, and muscle contractures, expressed a desire not to be repositioned in bed. Despite this, a geriatric nursing assistant (GNA) attempted to turn the resident by pulling on their contracted fingers, resulting in a fracture of the resident's finger. The incident was documented in a facility-reported incident and medical records, which revealed that the resident experienced pain and swelling in the affected fingers. An initial x-ray conducted at the facility showed no fracture, but the resident insisted on further evaluation at the emergency room, where a fracture was confirmed. The resident reported ongoing pain and discomfort, particularly during weather changes, and expressed dissatisfaction with the handling of the situation by the GNA. Interviews with facility staff, including the Director of Nursing and the Nursing Home Administrator, indicated that the GNA involved had a history of conduct issues, including previous complaints of verbal abuse and falsification of documentation. The GNA was ultimately terminated following the incident. The resident described the GNA as rough and unyielding in their approach, which contributed to the incident and subsequent harm.
Failure to Employ Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a full-time licensed social worker despite having more than 120 certified beds, which is a requirement. The facility was licensed for 140 certified beds, and the absence of a full-time social worker was evident from the complaints and interviews conducted. A responsible party for one resident complained about the lack of communication from the social work department after the previous social worker left, leading to unresolved issues regarding the resident's care. Another responsible party reported difficulties in coordinating a discharge plan for a resident who had been in the facility since 2022, with no progress made after the previous social worker left. Interviews with staff revealed that the social work assistant, who was not a licensed social worker, was overwhelmed and handling all residents by herself. She was still pursuing her bachelor's degree and was not fully aware of the procedures for notifying family members about care plan meetings. The facility had been without a licensed full-time social worker since December 2022, despite attempts to recruit candidates. Supervision was provided by a corporate staff member who was not present in the facility on a full-time basis.
Environmental Deficiencies in Resident Rooms and Common Areas
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment for residents, as evidenced by multiple deficiencies observed during a complaint survey. In one instance, a resident's room was found to be unsanitary, with a toilet seat in disrepair, a malodorous atmosphere, and a floor that was soiled and sticky. The bathroom lacked essential supplies such as toilet tissue and hand towels, and the resident's closet compartments were in disrepair. Another resident's room had a bottom sheet with holes and stains, a molding strip hanging down, soiled window blinds, and a radiator with mold-like material. Additionally, the room's lamp was broken and dirty, and the over-bed tray table had missing laminate. Further observations revealed environmental concerns throughout the facility, including a hallway with base molding pulled away from the wall, dining room wheelchairs with cracked vinyl armrests, and a resident's room with cracked linoleum tiles and peeling drywall. Another room had a missing nightstand door and damaged laminate on the footboard. These findings were discussed with the corporate nurse, who acknowledged the concerns, including the presence of mold in the radiator.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required 2-hour timeframe to the Office of Health Care Quality (OHCQ) for five incidents. In one case, a resident reported to a hospital social worker that they had been hit by a staff member, but the facility's report was not received by OHCQ until the following day. Another incident involved a resident who communicated via phone that they had been spit on by a staff member, but the facility's report lacked a submission time, and no email confirmation was available. Additionally, a resident complained of pain and swelling after a staff member allegedly pulled their hand, but the facility could not confirm the report was sent within the required timeframe. Further incidents included a resident who reported pain after a GNA ignored their request not to be turned, resulting in swelling and pain in their hand. The facility's investigation did not produce an email confirmation of the report submission. Lastly, a GNA was informed by police to stay away from a resident after an alleged abuse incident, but the facility delayed reporting this to OHCQ. Interviews with the Director of Nursing (DON) revealed a lack of email confirmations for the report submissions, indicating a failure to adhere to reporting protocols.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility staff failed to conduct quarterly care plan meetings for several residents, as required. This deficiency was identified during a complaint survey, where it was found that seven residents did not have their care plans reviewed and revised quarterly. The care plans are essential for providing individualized care and ensuring that the interventions are accurate and appropriate for each resident. The lack of quarterly meetings was confirmed through interviews with the Director of Nursing and review of medical records. For Resident #5, there were no quarterly care plan meetings from admission in July 2022 until July 2024. Similarly, Resident #9 did not have any care plan meetings from April 2023 until discharge, and Resident #10 lacked meetings from admission in January 2024 until discharge. Resident #17 did not have any meetings from February 2023 until September 2024, and a meeting was only held after surveyor intervention. These lapses were confirmed by the Director of Nursing and the Administrator. Additionally, Resident #4's responsible party reported a lack of communication from the social work department after the social worker left, and no care plan meetings were held after September 2023. Resident #1's responsible party faced difficulties in coordinating a discharge plan due to the absence of care plan meetings after June 2023. Resident #2's medical record also lacked evidence of care plan meetings since admission in June 2023. These issues were discussed with the Corporate Administrator and Nurse during the exit conference.
Medication Administration and Risk Assessment Failures
Penalty
Summary
The facility failed to provide adequate care for several residents, as evidenced by multiple deficiencies in medication administration and risk assessment. Resident #7, diagnosed with opioid dependence, did not receive Methadone as ordered by the physician on numerous occasions in July and August 2024. This failure was confirmed by the Regional Nurse. Similarly, Resident #8 did not receive prescribed medications for seizures and gastrointestinal ulcers on two consecutive days in July 2024, as confirmed by the Director of Nursing. Resident #10, who was diagnosed with bilateral dry eye syndrome, did not receive prescribed artificial tears and lid scrubs in a timely manner. The eye doctor recommended these treatments on March 22, 2024, but they were not administered until April 16, 2024. This delay in treatment was confirmed by the Director of Nursing. Additionally, Resident #24's risk for elopement was inaccurately assessed, as the resident had a history of leaving the facility without notifying staff, yet this was not documented correctly in the Wandering Observation Tool. Resident #3, who was admitted with hypotension and other conditions, received Midodrine despite having a systolic blood pressure above the physician-ordered parameters. The medication was administered when the resident's blood pressure was 130/70, contrary to the order to hold the medication if the systolic blood pressure exceeded 120. This error was confirmed by Staff #13, who acknowledged the failure to follow the care plan related to medication administration.
Failure to Reassess Pressure Ulcer
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for Resident #40. The resident was readmitted to the facility with a Stage III pressure ulcer on the sacrum. The Wound Nurse Practitioner assessed the wound and documented its measurements on 3/3/24. However, the facility staff did not reassess the sacral pressure wound weekly as required, specifically failing to do so on 3/10/24. The resident was subsequently discharged to the hospital on 3/15/24. An interview with the Director of Nursing confirmed the failure to reassess the wound on the specified date.
Dignity Violation: Residents Pulled Backwards in Hallways
Penalty
Summary
Facility staff failed to treat residents in a dignified manner, as evidenced by two separate incidents observed during a complaint survey. In the first incident, a licensed practical nurse (LPN) was observed pulling a resident backwards down two hallways from the dining room to the resident's room. In the second incident, a geriatric nursing assistant (GNA) was seen pulling another resident backwards down a hallway and into an activity room. When questioned by a surveyor, the GNA was unable to identify the resident by name, and the resident had to state their own name. These observations were confirmed as dignity issues by a staff member during an interview.
Failure to Notify Physician of Low Blood Pressure
Penalty
Summary
The facility staff failed to notify a resident's physician of a significant change in the resident's condition, specifically a low blood pressure reading. The medical record review revealed that the resident was admitted to the facility and later transferred to the hospital, not returning to the facility. On a specific date, the resident's blood pressure was recorded as 73/49 mmHg, which is below the normal range. Despite this critical reading, there was no documentation indicating that the physician was notified of the low blood pressure. An interview with the Director of Nursing confirmed that the physician should have been informed of this change in the resident's status, but there was no evidence of such notification in the medical record.
Failure to Provide Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to provide a baseline care plan to a resident and their representative within 48 hours of admission, as required. This deficiency was identified during a complaint survey involving three residents, with one resident specifically affected. The baseline care plan is crucial as it outlines the initial goals, physician orders, therapy services, dietary services, and social services intended for the resident. In this case, the medical record review revealed no evidence that the resident or their representative received this summary within the stipulated timeframe. An interview with the Regional Nurse confirmed the oversight, highlighting a lapse in communication and documentation processes at the facility.
Failure to Address Elopement Risk in Care Plan
Penalty
Summary
The facility staff failed to ensure that a resident's care plan included individual care needs and interventions, specifically for the risk of elopement. This deficiency was identified during a complaint survey for one resident out of 51 reviewed. The medical record review revealed that the resident left the facility without notifying staff to visit a family member's house. Additionally, a nurse's note indicated that the resident was found sitting alone by an exit door, requesting to leave, but was reminded of a medical order prohibiting unaccompanied exits. Despite these incidents, the resident's care plan did not address the risk of elopement, which was confirmed by the Director of Nursing during an interview.
Failure to Develop and Update Discharge Plan
Penalty
Summary
The facility failed to develop an individualized discharge plan and update a discharge care plan for a resident admitted for rehabilitation. The resident, who had been in the facility since 2023 following a three-month hospital stay due to an accident, had a discharge care plan initiated in November 2023. This plan documented the resident's and responsible party's wish for the resident to be discharged back to Washington State with family when care was adequate for discharge. However, as of September 2024, the care plan had not been updated or evaluated with current interventions, and there was no documentation of an active discharge plan in process. Interviews with the resident's responsible party and facility staff revealed communication and documentation issues. The responsible party had been trying to facilitate the resident's return home since January 2024 but faced difficulties due to staff changes and lack of action. The social work assistant, who was working without a director, acknowledged conducting a care plan meeting but failed to document it in the medical record. The Director of Nursing and Nursing Home Administrator were unaware of the discharge issue until informed by the Ombudsman. The lack of documentation and coordination contributed to the deficiency in discharge planning for the resident.
Failure to Provide Proper Colostomy Care and Supplies
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident with a colostomy, as evidenced by the review of medical records and interviews. The resident, who had a diagnosis of malignant neoplasm, was supposed to receive colostomy care every shift as per the attending provider's orders. However, these orders were discontinued without proper documentation or explanation. Additionally, the facility did not ensure the availability of necessary colostomy supplies, leading to the resident's family having to purchase colostomy bags themselves. The family reported that the bags they purchased were not properly secured, resulting in leakage. During the survey, it was discovered that the colostomy bags available in the facility required a clip to secure them, but one of the bags was found stapled shut, indicating improper handling. The Director of Nursing (DON) was informed of the situation, but there was no response provided at the time of the survey. This deficiency highlights a lack of adherence to care protocols and inadequate supply management, which compromised the resident's colostomy care.
Deficiencies in Medical Record Maintenance and Accuracy
Penalty
Summary
The facility failed to maintain access to all closed medical records and ensure the accuracy of electronic medical records, as evidenced by the cases of three residents. For one resident, the facility could not provide the closed medical record upon request during a complaint survey. The medical records director explained that the facility uses an offsite vendor for storing closed records and that a flood in 2019 had led to the disposal of several charts. Despite an expedited request, the closed medical record for this resident could not be located by the offsite vendor. In another instance, the electronic medical record for the same resident contained a psychiatric nurse practitioner's progress note dated after the resident had eloped from the facility and not returned. The psychiatric nurse practitioner confirmed conducting consultations in person during that period and billing records showed a charge for the consultation. However, the resident was not present in the facility at the time of the documented consultation. Additionally, the facility inaccurately documented vital signs for another resident who had already been discharged. The regional nurse confirmed the inaccuracy. Furthermore, the facility was unable to provide the medical record for a third resident, which was needed to verify the inventory of personal belongings upon readmission. The DON acknowledged the deficiency when the offsite company could not locate the chart.
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.
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