Waldorf Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waldorf, Maryland.
- Location
- 4140 Old Washington Highway, Waldorf, Maryland 20602
- CMS Provider Number
- 215273
- Inspections on file
- 15
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Waldorf Center during CMS and state inspections, most recent first.
Surveyors found that medical records containing PHI were stored in a shared warehouse used for general storage, where open and closed boxes of records had resident names, MRNs, and assessments freely visible on box exteriors and file covers. The warehouse was unlocked for surveyors by maintenance staff, and the Director of Maintenance reported that central supply, housekeeping, and dietary staff had access. The DON later confirmed that maintenance and environmental services did not need access to PHI, yet acknowledged that multiple non-clinical staff, including maintenance and environmental services leadership, had keys to the warehouse where these records were kept.
Surveyors identified multiple infection control failures, including an activities assistant placing a personal cell phone on a resident’s bed, improper storage and management of biohazard waste in a warehouse where clean medical supplies, gloves, drinking cups, and other items were stored without separation or off-floor protection, and disorganized handling of clean and soiled linens. In the clean laundry area, uncovered facility linens and unidentified resident garments were piled, leaning on walls, and in some cases touching the floor. In the soiled laundry area, overflowing unlined bins and containers held unbagged resident laundry and facility linens piled high against walls in an odorous room, with only one functioning washing machine contributing to the accumulation of soiled items.
Surveyors found that MDS assessments were inaccurately coded for tobacco use for two residents. Both residents told surveyors they were smokers, and facility smoking lists and prior Smoking Evaluations identified them as independent smokers. Despite this, their annual MDS assessments documented "No" for tobacco use in section J1300, indicating that known information about their smoking status was not accurately reflected in the MDS.
Surveyors found that the facility did not develop complete, person-centered care plans for a resident at risk for falls and two residents who were independent smokers. For the fall-risk resident with a history of CVA and impaired mobility, the care plan goal of avoiding falls with injury lacked specific, measurable interventions, including incomplete directions about fall mat use and which personal items should be kept within reach. For the two independent smokers, smoking assessments and goals for safe smoking were documented, but the care plans did not include any specific interventions or services to support those goals.
An LPN administered a PRN oxycodone dose to a resident for pain but failed to document the administration on the MAR, even though the narcotic control book showed the medication was signed out. In separate med pass observations, the same LPN gave multiple 9:00 AM scheduled medications, including metformin, Eliquis, antihypertensives, diuretics, GI meds, supplements, and inhaled therapy, to two residents more than an hour late, with the eMAR highlighting the overdue status. The LPN acknowledged the late administration and cited responsibility for two hallways of residents.
The facility failed to ensure proper cleaning and air drying of food preparation equipment, potentially affecting 103 residents. The AMD confirmed that the meat slicer had food remnants and several pans were stacked wet, contrary to facility policies requiring equipment to be cleaned and air dried before storage.
The facility failed to properly dispose of garbage in the dumpster area, affecting 110 residents and staff. An observation revealed an open dumpster and a ripped trash bag on the ground. The AMD confirmed that dumpsters should be closed and trash bags placed inside. The facility's policy requires trash to be contained in covered, leak-proof containers and disposed of in external receptacles, with the area kept free of debris.
The facility failed to provide residents with preplanned menus and alternative food options, resulting in residents not being able to choose their meals. Interviews and observations revealed that residents were not consistently informed of their meal options, especially those in isolation or unable to leave their rooms. Staff acknowledged the lack of a formal policy for menu distribution and preference collection, leading to meals not aligning with residents' preferences.
The facility failed to address resident council concerns about meal menus and food preferences. Residents reported that their requests for weekly meal menus and consideration of their food preferences were repeatedly ignored. Despite documentation of these issues in resident council meeting notes, no resolution was implemented. Interviews revealed a lack of communication and follow-up by the Activity Manager, District Dietary Manager, and Administrator, and the facility lacked a policy to address resident group concerns.
The facility failed to follow infection control measures for two residents, increasing the risk of COVID transmission. An LPN did not sanitize hands after removing PPE in a COVID-positive resident's room, and a GNA mishandled trash and soiled laundry. Another LPN did not perform hand hygiene between glove changes during wound care for a resident on Enhanced Barrier Precautions.
The facility failed to maintain a clean and comfortable environment, with issues such as unpainted walls, peeling laminate, and damaged wheelchairs observed. Additionally, a resident's gold ring went missing after being placed in a medication cart for safekeeping, leading to an investigation and the termination of an LPN for gross misconduct. The facility lacked a policy for protecting residents' property.
The facility failed to report allegations of abuse to the Office of Health Care Quality within the required 2-hour timeframe for two residents. In one instance, a staff member reported witnessing another staff member hitting a resident, but the report was delayed by seven days. In another case, a resident alleged that an LPN waved her finger in their face, but the report was delayed until the following day due to distractions from surveyors in the building.
The facility failed to thoroughly investigate an alleged abuse incident involving a resident. A staff member reported witnessing another staff member hitting a resident's hand, but the investigation was incomplete. It lacked the reporting staff's statement and did not include statements from other staff or residents who interacted with the accused staff member. The Administrator and DON confirmed the investigation's inadequacy.
The facility failed to hold quarterly care plan meetings and involve residents or their representatives in care planning. One resident had no care plan meetings in the past year, while another had only one meeting during their stay. The DON confirmed these deficiencies, and facility policies were not provided during the survey.
A facility failed to schedule a follow-up colonoscopy for a resident with gastrostomy status, GERD, and peptic ulcer, as ordered by a physician. A consultation report recommended a repeat colonoscopy due to poor colon preparation, but no documentation of the procedure was found. Staff interviews revealed that the responsibility for scheduling appointments lay with the unit manager or nurse, but the DON confirmed that the follow-up was not scheduled or performed.
A resident with a Stage IV pressure ulcer on the sacrum did not receive timely wound care as per physician orders. Upon admission and subsequent readmissions, there were significant delays in initiating the prescribed wound treatments, ranging from seven to ten days. These delays were confirmed by the DON, highlighting a pattern of non-compliance with wound care protocols.
A resident with a left second toe amputation did not receive proper wound care as ordered by the physician. The facility staff failed to cleanse and dress the surgical site on multiple occasions, and there were no nursing progress notes or wound notes to confirm that the care was provided. This deficiency was identified during a complaint survey.
A facility failed to administer prescribed respiratory inhalers for a resident with COPD/Asthma exacerbation, as indicated by blank spaces on the MAR for specific dates. The resident's care plan, which included administering aerosol treatments, was not followed. The DON confirmed that the nurse responsible no longer worked at the facility, and there was no documentation to confirm the treatments were provided.
A facility failed to document the administration of PRN Dilaudid (Hydromorphone) for a resident and did not monitor the resident's pain level or the medication's efficacy. The medication was removed from the controlled lock box on several occasions, but these administrations were not recorded on the MAR, as confirmed by the Administrator.
During a complaint survey, facility staff failed to keep medication and treatment carts locked when unattended. On the B wing, two medication carts were found unlocked and unattended, with accessible drawers containing resident medications. Additionally, a treatment cart was found unlocked on both the B and A wings, containing medicated ointments and other supplies. Staff members were informed but seemed unaware or indifferent to the issue. The facility's policy requires medication supplies to remain locked when not in use.
Facility staff failed to follow up with outside resources for a resident's oral surgery post-operative instructions. The resident had three teeth extracted and was given written instructions, but these were not documented in the medical record. An interview confirmed the lack of follow-up with the oral surgeon.
The facility lacked an effective pest control program, resulting in a widespread gnat problem. A resident complained about gnats in their wheelchair, and another resident's meal was affected by gnats. The issue was confirmed by a CMA and observed in the NHA's office. The NHA admitted the facility only recently secured a pest control contract.
A cognitively intact resident was not invited to their care plan meetings, despite having full decision-making capacity. The resident's mother attended the meetings instead, and discussions about the resident's care were held with her. Facility staff misunderstood the resident's competency status, leading to this oversight.
A facility failed to provide written notification of transfer to a resident or their family/representative. A resident, who was severely cognitively impaired and dependent on ADLs, was transferred to the emergency room after sustaining a head injury. The facility did not provide written notification of this transfer, and the Administrator confirmed that such notifications were not being issued.
A resident with mental disorders and intellectual disabilities did not receive a required PASARR Level II evaluation after remaining in the facility for over 40 days. The resident's medical records showed moderate cognitive impairment and impulsive behaviors, but the facility failed to request the necessary screening from the State Agency, as confirmed by staff interviews.
Two residents, both cognitively intact but dependent on staff for ADLs, were found with long and soiled fingernails. Despite being reliant on staff for personal hygiene, their nails remained untrimmed and dirty over several days. An LPN and the DON confirmed that GNAs were responsible for nail care, but the facility failed to provide a policy for ADL care upon request.
A resident with impaired range of motion in the left upper extremity did not consistently receive a prescribed hand splint, as observed during multiple checks. The resident was unable to apply the splint independently and staff were unaware of the order. The Director of Rehab confirmed the splint was missing, and the Director of Nursing stated that nursing staff were responsible for implementing the care plan, which was not followed.
A pharmacist failed to monitor adverse consequences and target behaviors for a resident prescribed Seroquel for agitation, despite the resident's severe cognitive impairment and Alzheimer's diagnosis. The Medication Regimen Review did not address the use of Seroquel or the need for monitoring, and the pharmacist could not provide specific information due to database access issues.
A facility failed to monitor the use of Seroquel for a resident with Alzheimer's and Parkinsonism, who was prescribed the medication for agitation despite no signs of distress. The care plan lacked specific monitoring for side effects or target behaviors, and observations showed the resident was calm. The DON confirmed the absence of adequate monitoring, violating the facility's medication management policy.
Unsecured Storage of Medical Records with Visible PHI in Shared Warehouse
Penalty
Summary
The facility failed to ensure privacy and confidentiality of medical records when surveyors observed resident medical records stored in an unsecured warehouse building. During a dual surveyor observation conducted in connection with a complaint investigation, the Director of Maintenance and Assistant Director of Maintenance unlocked the warehouse, where surveyors saw several open boxes of medical records in different areas of the warehouse with freely visible protected health information, including resident names and medical record assessments. In another area of the warehouse, surveyors observed approximately 11 closed boxes of medical records with papers affixed to the exterior showing visible resident names and medical record numbers, as well as medical record files sitting on top of the boxes with names and other information written on the outside of the files. During the same observation, the Director of Maintenance stated that the warehouse was used by "everybody" to put items in and that it served as additional storage. When surveyors asked who had access to the warehouse, the Director of Maintenance identified the central supply staff, housekeeping, and dietary staff as having access. In a subsequent interview, the DON confirmed that maintenance and environmental services staff did not need access to medical records or protected health information, yet reported that the Maintenance Director, Environmental Services Director, Medical Records/Supply person, and Maintenance Assistant all had keys or access to the warehouse where the medical information was stored. These observations and interviews established that medical records containing protected health information were stored in a location accessible to multiple non-clinical staff, with resident-identifying information openly visible.
Inadequate Infection Control in Warehouse Storage, Laundry Handling, and Resident Care Area
Penalty
Summary
The deficiency involves failures in basic infection prevention and control practices, beginning with improper handling of personal items in a resident care area. An activities assistant placed their personal cell phone directly onto a resident’s bed while accessing the resident’s furniture with a key. The assistant acknowledged that the phone was personal, and the concern was recognized by the facility’s Director of Nursing, who stated the assistant had been rushed and not thinking when placing the phone on the bed. Additional deficiencies were identified in the facility’s warehouse storage area during a dual surveyor observation conducted with the Director and Assistant Director of Maintenance. Surveyors observed biohazard waste stored in the same area as open boxes of clean medical gloves and other clean medical supplies, with boxed biohazard waste stacked against boxes of clean items. An opened box of drinking cups and cup lids was stored on the floor near a plastic container of used belongings, including a worn and cracked wheelchair armrest. Lancets, medical tape, and various expired syringes were present without separation of clean and dirty items, and boxed medical supplies such as gloves, incontinence briefs, wound cleanser, and dressing supplies were stored directly on the floor. The Infection Preventionist confirmed that these storage and biohazard management conditions were not acceptable and stated that biohazard waste should never be stored with clean items. Further infection control concerns were identified in the clean and soiled laundry processing areas. In the clean laundry area, surveyors observed an uncovered metal linen cart with facility blankets, towels, washcloths, and sheets piled high, leaning on the wall, and stored close to the floor. There was also an uncovered laundry basket with a pile of clean, unfolded, unidentified resident laundry overflowing and leaning against the wall, along with three additional uncovered containers of unidentified resident laundry under folding tables, one of which had items touching the floor. In the soiled laundry area, multiple unlined large trash bins were overflowing with unbagged resident laundry and facility linens piled high and touching the wall, along with additional containers and a tilt truck filled with bagged and unbagged soiled linens, and the room was described as odorous. The Environmental Services Manager and District EVS Manager confirmed these conditions and the associated infection control concerns, noting that only one of two washing machines was operational, contributing to the volume of soiled laundry present.
Inaccurate MDS Coding of Resident Tobacco Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments were accurately coded to reflect residents’ current tobacco use status. Two residents who were identified as smokers through interviews with the surveyor and facility documentation were coded as non-smokers on their annual MDS assessments. One resident reported to the surveyor that they were a smoker, and the facility’s smoking list and a prior Smoking Evaluation dated 9/2/2025 identified this resident as an independent smoker. However, the resident’s annual MDS assessment completed on 9/22/2025 documented “No” for tobacco use in section J1300. Similarly, another resident informed the surveyor that they were a smoker, and the facility’s smoking list and a Smoking Evaluation dated 12/3/2025 showed that this resident was also an independent smoker. Despite this, the resident’s annual MDS assessment completed on 12/06/2025 recorded “No” for tobacco use in section J1300. During interviews, the MDS Coordinator acknowledged that tobacco use should have been captured on the annual MDS for one of the residents, and the Corporate Clinical Lead was informed by the surveyor that the other resident’s annual MDS did not reflect current tobacco use. These findings demonstrate that existing information about residents’ smoking status was not accurately incorporated into their MDS assessments.
Incomplete and Non-Specific Care Plans for Fall Risk and Independent Smokers
Penalty
Summary
Surveyors identified that the facility failed to develop and implement comprehensive, individualized care plans for multiple residents. For one resident reviewed for change in condition, the care plan included a focus of risk for falls related to CVA and impaired mobility, with a goal of no falls with injury for 90 days. However, specific interventions were left incomplete: the intervention for fall mats did not indicate the number or sides to be used, and the intervention directing staff to place personal items within reach did not specify which personal items. During review, the DON acknowledged that this care plan was not sufficiently personalized or specific to the resident’s needs. For two residents reviewed for accidents who were identified as independent smokers, the facility failed to develop complete person-centered care plans that included specific interventions. Both residents had smoking evaluations indicating they were independent smokers, and each had a care plan focus stating that the resident may smoke independently per smoking assessment, with goals that the resident would smoke safely by the next review or for 90 days. Despite this, the care plans did not include any detailed interventions describing the specific care and services to be implemented to meet the stated goals for safe smoking. This lack of defined interventions for independent smokers was confirmed during record review and staff interview.
Failure to Document PRN Narcotic and Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves failure to follow professional standards of practice during medication administration and documentation. During an observation, an LPN removed and administered a 5 mg oxycodone tablet to a resident who complained of an upset stomach and headache, signing the narcotic control book when removing the medication from the narcotic drawer. Subsequent medical record review showed the resident had a PRN order for oxycodone 5 mg by mouth every four hours as needed for pain rated 4–6, but the medication administration record (MAR) did not show that the oxycodone dose was documented as administered, despite confirmation in the narcotic book that it had been signed out for that resident. Additional deficiencies were identified during medication pass observations for two other residents when an LPN administered multiple scheduled medications significantly later than the ordered time. For one resident, medications including metformin, Eliquis, aspirin, metoprolol, amlodipine, cetirizine, furosemide, omeprazole, a multivitamin, and fluticasone inhalation were scheduled for 9:00 AM but were administered at 10:30 AM, with the electronic MAR screen highlighted in pink to indicate they were not given at the scheduled time. For another resident, medications and supplements including protein liquid, amlodipine, metoprolol, a multivitamin with minerals, sodium bicarbonate, Vitron-C, and omeprazole were also scheduled for 9:00 AM but were administered at 10:45 AM, again with the computer screen highlighted in pink. The LPN acknowledged in both cases that the medications were given outside the scheduled ordered time and explained she was responsible for two hallways of residents.
Improper Cleaning and Drying of Kitchen Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and air drying of food preparation equipment, which could potentially increase the risk of foodborne illness for 103 of the 110 residents receiving dietary services. During an observation, the Account Manager Dietary (AMD) confirmed that the meat slicer blade had food remnants on it and needed cleaning before use. The AMD stated that it was expected for the meat slicer to be properly cleaned after each use, as per the facility's policy, which mandates that all food contact equipment be cleaned and sanitized after each use. Additionally, during another observation, the AMD confirmed that several pans, which were cleaned and stacked for use, were still wet and had not been allowed to air dry before storage. The facility's policy requires all cookware and service ware to be air dried prior to storage. These deficiencies in cleaning and drying procedures were observed and confirmed by the AMD, highlighting a failure to adhere to the facility's established policies for maintaining sanitary conditions in food preparation areas.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to ensure proper disposal and containment of garbage in the dumpster area, affecting 110 residents and staff. During an observation, it was noted that one of the two dumpsters used for trash and recycling was left open, and a large trash bag was found ripped open on the ground between the dumpsters. The Account Manager Dietary (AMD) confirmed that dumpsters should be closed and trash bags should be placed inside the dumpsters, not left on the ground. The facility's policy, dated September 2017, mandates that all trash be contained in covered, leak-proof containers to prevent cross-contamination and be properly disposed of in external receptacles, with the surrounding area kept free of debris.
Failure to Provide Meal Choice and Menu Information
Penalty
Summary
The facility failed to provide preplanned menus and a list of alternative foods to residents, resulting in a lack of opportunity for residents to choose their meals. This deficiency was observed in four residents, all of whom were cognitively intact and capable of making their own meal choices. The residents reported not being asked about their meal preferences and not being informed of the available menu options. This led to residents receiving meals that did not align with their preferences, such as one resident preferring oatmeal but receiving scrambled eggs instead. Interviews with staff revealed a lack of a formal policy for distributing menus and collecting residents' meal preferences. The District Manager of Dietary and the Director of Nursing both acknowledged that there was no established process for ensuring residents were informed of their meal options. The nursing department was supposed to distribute menus and collect preferences, but this was not consistently done, especially for residents in isolation or those unable to leave their rooms. Observations further confirmed the inconsistency in meal service. Residents in isolation did not receive menus during their isolation period, and some residents received meals that did not match the menu or their preferences. The dietary manager stated that menus were posted in common areas, but this did not address the needs of residents who remained in their rooms. The facility's failure to ensure residents were informed of their meal options and preferences contributed to the deficiency.
Failure to Address Resident Council Concerns on Meal Preferences
Penalty
Summary
The facility failed to address the concerns and requests of the resident council regarding meal menus and food preferences. Five residents who regularly attended the resident council meetings expressed that their requests for weekly meal menus and consideration of their food preferences had been repeatedly ignored. During a group interview, residents reported that they had not received any rationale for their unmet requests, and their concerns were documented in the resident council meeting notes over several months without resolution. The Activity Manager (AM) had documented plans to address these issues, such as providing menus and surveying residents for meal preferences, but these actions were not implemented. Interviews with facility staff revealed a lack of communication and follow-up on the residents' grievances. The AM acknowledged awareness of the residents' requests but could not provide documentation of any communication with the dietary department. The District Dietary Manager (DM) was aware of the concerns but had not acted on proposed solutions, such as the mock plate discussion. The Administrator was also aware of the issues but had not ensured that the dietary staff responded to the resident council's concerns. The facility lacked a policy to address resident group concerns, contributing to the ongoing deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, increasing the risk of COVID transmission and cross-contamination. For Resident 31, a physician ordered strict isolation and droplet precautions due to a COVID-positive diagnosis. However, during wound treatment, an LPN did not sanitize or wash her hands after removing PPE in the resident's room, citing a non-functional sanitizer dispenser. Additionally, a GNA improperly handled trash and soiled laundry from the resident's room, placing them on the hallway floor and failing to label the laundry for separate washing, which was confirmed by the laundry worker and the Infection Preventionist. For another resident, R1, who was on Enhanced Barrier Precautions due to a feeding tube, urinary catheter, and non-healing pressure ulcers, an LPN failed to perform hand hygiene between glove changes during wound care. The LPN changed gloves multiple times without sanitizing her hands, even after touching the dresser and bed rails. This was verified by another LPN assisting with the procedure and the Infection Preventionist, who confirmed that hand hygiene was expected between all glove changes.
Deficiencies in Facility Maintenance and Resident Property Protection
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment in two of the three nursing units and the dining room. Observations revealed unpainted spackled areas, peeling laminate on dresser drawers, and stained privacy curtains in resident rooms. Additionally, wheelchairs in the dining room had missing or damaged armrests, exposing the padding underneath. The Maintenance Director acknowledged the issues with the wheelchairs and stated that audits are conducted every two months, but the Nursing Home Administrator could not provide invoices for replacement parts. The facility also failed to protect a resident's personal property from loss or theft. A grievance was filed by a family member regarding a missing gold ring belonging to a deceased resident. The ring was initially secured by the facility but was later reported missing after being placed in a medication cart for safekeeping. The investigation revealed that the last known staff member to have possession of the ring failed to inform the oncoming nurse of its location, leading to its disappearance. The facility was unable to determine if the staff member took the ring, but he was terminated for gross misconduct. The facility did not provide a policy related to protecting residents' property, and the investigation into the missing ring involved staff interviews and re-education on handling personal property. The incident was reported to local law enforcement, the State Agency, and the Long-Term Care Ombudsman. Despite these actions, the facility was unable to locate the missing ring, and the family was informed of the situation.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. This deficiency was identified during an annual survey for two residents. In the first case, a staff member reported witnessing another staff member hitting a resident's hand, but the incident was reported to OHCQ seven days later. The Director of Nursing and Administrator confirmed the delay in reporting. In the second case, a resident alleged that an LPN waved her finger in the resident's face. The allegation was reported to the Nursing Home Administrator by a surveyor, but the report to OHCQ was delayed until the following day. The Nursing Home Administrator attributed the delay to being distracted by surveyors in the building.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. On 8/14/24, a review of a facility-reported incident revealed that a staff member reported witnessing another staff member hitting a resident's hand on 5/19/22. The facility's investigation was found to be incomplete as it did not include the name or statement of the reporting staff member, nor did it contain statements from other staff who were present on the day of the alleged incident, except for the accused staff member. Additionally, the facility did not obtain statements from other residents who received care from the accused staff member to determine if there were further concerns of abuse. An interview with the Administrator and Director of Nursing confirmed that the facility staff failed to complete a thorough investigation of the alleged abuse incident.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to conduct quarterly care plan meetings for residents and did not invite residents or their representatives to participate in the development of their care plans. This deficiency was identified for three residents during the review. For one resident, admitted with diagnoses including nontraumatic intracranial hemorrhage and chronic kidney disease, there was no record of any care plan conference being held, despite the availability of baseline and comprehensive care plans. A family member confirmed not being invited to any care plan meetings, and the Social Services Coordinator acknowledged that care plan meetings had not been held for this resident in the past year. Additionally, another resident had only one care plan meeting during their stay, and a third resident had no care plan meetings after an initial one, until their discharge. The Director of Nursing confirmed the absence of quarterly care plan meetings for these residents. Facility policies regarding care plans and meetings were requested but not provided during the survey.
Failure to Schedule Follow-Up Colonoscopy
Penalty
Summary
The facility failed to schedule a follow-up colonoscopy for a resident as per the physician's orders. The resident, admitted in August 2022, had diagnoses including gastrostomy status, GERD, and peptic ulcer. A consultation report dated April 19, 2023, indicated poor colon preparation and recommended a repeat colonoscopy in one month. The report included a note to schedule the procedure, but there was no documentation of the follow-up colonoscopy being performed. Interviews with staff revealed that the responsibility for scheduling such appointments lay with the unit manager or nurse on the unit. However, the Director of Nursing confirmed that no follow-up colonoscopy was scheduled or performed, and the last recorded visit to the GI office was in December 2023 for G-tube removal.
Failure to Provide Timely Wound Care for Resident
Penalty
Summary
The facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident with a Stage IV pressure ulcer on the sacrum. Upon admission to the facility, the resident had a physician's order for wound treatment twice daily, but the treatment was not initiated until seven days after admission. This delay in treatment was documented in the resident's Treatment Administration Record (TAR) for December 2023. Further deficiencies were noted upon the resident's readmissions from hospital stays. On two separate occasions, the facility staff failed to begin the ordered wound treatment for the sacral wound in a timely manner. After a hospital stay in April 2024, the treatment was delayed by seven days, and following another hospital stay at the end of April 2024, the treatment was delayed by ten days. These delays were confirmed by the Director of Nursing during an interview, indicating a pattern of non-compliance with physician orders for wound care.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility staff failed to provide proper foot care and treatment for a resident, which was identified during a complaint survey. The resident was admitted with a diagnosis of amputation of the left second toe. On 8/16/23, a physician ordered specific wound care instructions for the surgical site, including cleansing with wound cleanser, patting dry, and covering with a dry dressing daily during the day shift. However, medical records revealed that on multiple dates, including 8/16, 8/18, 8/20, 8/23, and 8/26, the surgical site was not cleaned and dressed as ordered by the physician. An interview with the Director of Nursing on 8/20/24 confirmed that there were no nursing progress notes or wound notes in the medical record to indicate that the wound care was performed according to the physician's orders. This lack of documentation and adherence to the prescribed wound care regimen led to the deficiency identified in the report.
Failure to Administer Respiratory Inhalers as Ordered
Penalty
Summary
The facility failed to administer respiratory inhalers as ordered for a resident who required respiratory treatment. This deficiency was identified during a review of a complaint, medical records, and staff interviews. The resident in question had a history of respiratory failure secondary to COPD/Asthma exacerbation and was admitted to the facility from the hospital. The resident was prescribed Budesonide and Ipratropium-Albuterol inhalers to be administered twice daily for shortness of breath and wheezing. However, the Medication Administration Record (MAR) for March and April 2023 showed that the inhalers were not administered on specific dates, as indicated by blank spaces on the MAR. The care plan for the resident, which included administering aerosol treatments as ordered, was not followed. During an interview with the Director of Nursing (DON), it was revealed that the nurse responsible for administering the inhalers on the dates in question no longer worked at the facility, and there was no documentation in the nurse's notes to confirm that the respiratory treatments were provided. This lack of documentation and failure to administer the prescribed inhalers as ordered led to the identified deficiency.
Failure to Document and Monitor PRN Pain Medication Administration
Penalty
Summary
The facility failed to consistently document the administration of an as-needed (PRN) pain medication, Dilaudid (Hydromorphone), for a resident, as evidenced during a complaint survey. The resident's primary physician had ordered the medication to be given every six hours as needed for pain. However, a review of the Controlled Medication Utilization Record showed that the medication was removed from the controlled lock box on several occasions in December 2023 and January 2024, but the administration was not documented on the Medication Administration Record (MAR). Additionally, the resident's pain level and the efficacy of the medication were not monitored. An interview with the Administrator confirmed that the facility staff failed to ensure the medication was given as needed for pain.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to keep medication and treatment carts locked when unattended, as observed during a complaint survey. On the B wing nursing unit, an unlocked and unattended medication cart was found in the hallway outside the clean utility room. This cart remained unlocked and unattended for at least 13 minutes, during which time the surveyor was able to open all drawers containing resident medications. Another medication cart in the same hallway was also found unlocked and unattended, with accessible drawers containing medications. Licensed Practical Nurse (LPN) #1 was informed of the situation but seemed unaware of the issue. Additionally, an unlocked and unattended treatment cart was observed on the opposite hallway of the B wing nursing unit, containing medicated ointments and treatment modalities. Registered Nurse (RN) #2 was informed of the unlocked carts. On the A wing nursing unit, another unlocked and unattended treatment cart was found, containing scissors, bandages, prescription ointments, creams, and medicated dressings. LPN #9 was informed and responded with indifference. The facility's Medication Storage Policy, reviewed by the surveyor, clearly stated that medication supplies should remain locked when not in use or attended by authorized personnel. The Director of Nursing (DON) was informed of these observations.
Failure to Follow Up on Oral Surgery Post-Op Instructions
Penalty
Summary
The facility staff failed to follow up with outside resources for the care of a resident, specifically regarding oral surgery post-operative instructions. This deficiency was identified during a complaint survey involving one of the 45 residents reviewed. The resident was transported to an oral surgeon by a friend and had three teeth extracted. Although the resident was given written post-operative instructions, these instructions were not documented in the resident's medical record. An interview with the Administrator confirmed that the facility staff did not follow up with the oral surgeon to obtain the post-operative instructions.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous gnats throughout the building. During a complaint survey, gnats were observed in one of the three nursing units and public areas. A resident complained about gnats in their wheelchair, with at least ten gnats flying around the seat. A Certified Medicine Aide confirmed the gnat problem was widespread in the facility. In the dining room, another resident's lunch tray was observed with gnats flying on the fruit cocktail and BBQ sandwich. Additionally, gnats were seen in the Nursing Home Administrator's office, where surveyors were stationed for six days. The Nursing Home Administrator admitted that the facility did not have a pest control contract prior to the recent engagement of a new pest control company. Pest control logs were requested, but it was revealed that the facility had only secured a pest control contract in the past month, indicating a lack of prior pest management measures.
Failure to Include Competent Resident in Care Plan Meetings
Penalty
Summary
The facility failed to invite a cognitively intact resident, identified as Resident 41, to participate in their care plan meetings. Despite having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating full cognitive capacity, the resident was not informed or invited to the care plan meeting. Instead, the resident's mother attended the meeting, and discussions regarding the resident's care, including a referral to the rehab department and full code status, were held with her. Interviews with facility staff revealed a misunderstanding regarding the resident's competency status. The Social Services Coordinator incorrectly assumed the resident was not competent, despite documentation showing the resident had adequate decision-making capacity. The Director of Nursing confirmed that competent residents should be invited to their care plan meetings. The facility's policies on determining decision-makers and care plan meetings were requested but not provided by the time of the survey exit.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide a written notice of transfer to a resident or their family/representative, which was identified during a review of one of three residents hospitalized among 31 sampled residents. The resident in question, identified as R471, was severely cognitively impaired and dependent on all Activities of Daily Living (ADLs) except eating. On 10/07/23, a nurse's note documented that R471 was found with a head injury, bleeding from the forehead, after reportedly rolling over and hitting their head on the side rail. The resident was sent to the emergency room for further evaluation and returned to the facility without being admitted to the hospital. Upon reviewing the electronic medical record (EMR) and the resident's hard chart, it was found that no written notification of the transfer was provided to the family. During an interview, the facility's Administrator confirmed that the facility had not been providing written notifications of transfers to residents and/or their representatives. This oversight had the potential to leave residents or their representatives unaware of the transfer details and their rights to appeal.
Failure to Conduct PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure an accurate pre-admission screening and resident review (PASARR) Level II evaluation for a resident with mental disorders or intellectual disabilities. The resident, identified as R81, was admitted with diagnoses including moderate intellectual disabilities, bipolar disorder, schizoaffective disorder, unspecified psychosis, and anxiety disorder. Despite these conditions, the facility did not request a PASARR Level II screening from the State Agency after the resident remained in the facility for more than 40 days, as required by the exempted hospital discharge screening. The resident's medical records indicated a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of six out of 15. The care plan documented impulsive behaviors and impaired communication, highlighting the need for a comprehensive evaluation. Interviews with the Social Worker and Administrator confirmed the oversight, acknowledging the lack of a PASARR Level II evaluation and the absence of a facility policy related to PASARR, which contributed to the deficiency.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were cognitively intact but dependent on staff for activities of daily living (ADLs). The first resident, who had multiple sclerosis and functional quadriplegia, was observed with fingernails half an inch long and soiled with a black substance. Despite being totally dependent on staff for all ADLs, the resident's nails remained untrimmed and dirty over several days. The Licensed Practical Nurse (LPN) and Unit Manager confirmed the condition of the nails and stated that Geriatric Nursing Aides (GNAs) were responsible for nail care, as outlined in the GNA Plan of Care. Similarly, the second resident, who had limited mobility and was also dependent on staff for ADLs, was observed with fingernails half to one inch long and soiled. The resident expressed frustration over the condition of their nails. Observations over multiple days showed no improvement until the final day when the nails were trimmed and cleaned. The Director of Nursing (DON) confirmed that GNAs were responsible for nail care during resident showers or baths. The facility did not provide a policy for ADL care upon request before the survey exit.
Failure to Apply Hand Splint for Resident
Penalty
Summary
The facility failed to consistently apply a hand splint for a resident, identified as R72, who was at risk of further contractures due to impaired range of motion in the left upper extremity. The resident's electronic medical record indicated a physician's order for a left hand roll splint to be worn for four consecutive hours during the day shift, as well as a care plan for restorative splint assistance. However, during multiple observations, R72 was seen without the splint, and the resident reported not knowing where the splint was and being unable to put it on independently. Staff members, including a Geriatric Nurse Aide (GNA) and a Licensed Practical Nurse (LPN), were unaware of the splint order and could not locate the splint. The Director of Rehab confirmed that the splint could not be found, necessitating a reevaluation by therapy. The Director of Nursing verified that the nursing staff, particularly the GNAs, were responsible for implementing the restorative nursing care plan interventions, including the application of splints. The facility's policy on restorative nursing indicated that such programs should be coordinated by nursing or in collaboration with rehabilitation, with a licensed nurse supervising the activities. Despite these guidelines, the failure to apply the splint as ordered increased the risk of further loss of mobility and contractures for the resident.
Pharmacist's Failure to Monitor Antipsychotic Use
Penalty
Summary
The pharmacist failed to identify and monitor adverse consequences and target behaviors for a resident receiving antipsychotic medication. The resident, who was severely cognitively impaired with a BIMS score of three out of 15, was admitted with diagnoses including Alzheimer's disease and Parkinsonism, without any hallucinations, delusions, or aggressive behaviors. Despite this, a physician's order was placed for Seroquel, an antipsychotic medication, to address agitation. However, there was no consistent monitoring of the target behavior of agitation or adverse consequences associated with Seroquel use, especially given the resident's Alzheimer's diagnosis. The Medication Regimen Review conducted on a later date failed to address the use of Seroquel for agitation or the need for monitoring adverse consequences and target behaviors. The pharmacist only recommended discontinuing a Lidocaine patch due to nonuse. During an interview, the pharmacist was unable to provide specific information about the resident due to a lack of access to his computer database. The facility's policy required the attending physician and consultant pharmacist to re-evaluate psychotropic medication use and monitor for effectiveness and potential adverse consequences, which was not adhered to in this case.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and manage the use of psychotropic medication for a resident, identified as R107, who was severely cognitively impaired with Alzheimer's disease and Parkinsonism. Despite the absence of hallucinations, delusions, or aggressive behaviors, R107 was prescribed Seroquel, an antipsychotic medication, for agitation. The facility's care plan, initiated after the medication was prescribed, lacked specific side effects or target behaviors to monitor, and there was no plan for non-pharmacological interventions prior to using the antipsychotic medication. Observations and interviews with family members and staff indicated that R107 did not exhibit signs of agitation or distress during the review period. However, the facility's records, including the Medication Administration Record and Progress Notes, showed inconsistent monitoring of the target behavior of agitation and potential adverse effects of Seroquel. The Director of Nursing confirmed the lack of specific monitoring for adverse side effects or behaviors associated with the medication, which was contrary to the facility's medication management policy.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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