Westgate Hills Rehab & Healthcare Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 10 North Rock Glen Road, Baltimore, Maryland 21229
- CMS Provider Number
- 215299
- Inspections on file
- 19
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Westgate Hills Rehab & Healthcare Ctr during CMS and state inspections, most recent first.
Surveyors found that two residents did not receive care and treatment in accordance with professional standards, including lack of documentation before administering Nitroglycerin and inconsistent skin assessments leading to delayed wound care for a resident with MASD and a stage 3 pressure ulcer. Staff interviews confirmed documentation errors and delays in notifying practitioners and implementing wound care orders.
A resident with dementia and behavioral disturbances exhibited worsening agitation and wandering, but staff failed to assess or document these behaviors or implement behavior monitoring, relying instead on verbal reports. The DON confirmed that required documentation was missing from the medical record.
The facility did not ensure that the call bell system on the second floor was fully functional, resulting in the absence of an audible alert for staff when a resident activated the call bell. A resident with a tracheostomy reported extended wait times for assistance, and staff confirmed they could not hear the call bell sound. The deficiency was confirmed through observations, interviews, and review of complaints.
A resident with legal blindness reported being verbally abused by a GNA after a prolonged wait for assistance, with the incident witnessed by the resident's roommate. The facility's investigation was incomplete, lacking proper documentation of interviews with the alleged victim, witnesses, and staff, and no follow-up was conducted when another resident indicated awareness of abuse.
A facility failed to report an injury of unknown origin involving a resident to the State Agency within the required two-hour timeframe, instead reporting the incident nearly four hours after discovery. This delay was identified during a complaint survey through record review and staff interviews.
Facility staff did not thoroughly investigate allegations involving two residents, including concerns about care, hygiene, and verbal abuse. In both cases, not all issues raised by complainants were addressed, documentation was incomplete or missing, and required follow-up on potential abuse was not performed. The lack of comprehensive investigation and documentation resulted in unresolved allegations and inconclusive findings.
A resident dependent on staff for personal hygiene and incontinence care was left unbathed and soiled on multiple occasions. Documentation showed only two bed baths for the month instead of the scheduled nine, and there were significant gaps in incontinence care records. Staff interviews confirmed required documentation procedures were not followed, and the facility could not provide evidence that the resident received the necessary care as scheduled.
A resident developed a pressure injury on the right knee due to prolonged use of a knee brace without consistent skin assessments. Although the care plan called for regular skin checks under the immobilizer, documentation of these assessments was lacking for over a month, and staff interviews confirmed that such checks were expected regardless of specific orders. The deficiency was identified when the wound was discovered during a skin evaluation, revealing a lapse in preventive care.
A resident with a history of multiple falls and identified as high risk did not have all care plan fall prevention interventions in place. Observations showed the call pad was not within reach or on the correct side of the bed as required, and staff confirmed these interventions were not consistently implemented.
A resident experienced multiple incontinent episodes, but the GNA documented 'Not Applicable' for toileting hygiene instead of indicating whether care was provided or refused. The DON confirmed that staff should use the 'Resident Refused' option when care is declined, but the GNA reported being unable to do so and selected 'NA' instead, resulting in incomplete and inaccurate medical records.
Surveyors identified multiple instances of improper food storage and labeling, including unlabeled and unsecured food items in the kitchen refrigerator and freezer, as well as in the dry storage area. Additionally, the 2nd floor nourishment refrigerator contained a bag of deli meats without proper labeling or dating, despite staff-only access.
The facility failed to accurately document assessments for two residents. One resident's MDS assessment listed only a stage 3 pressure ulcer, despite wound care notes indicating both a stage 3 and a stage 2 ulcer. Another resident's discharge assessment incorrectly recorded a transfer to a hospital, while records showed the resident was discharged home. These errors were confirmed by MDS staff.
A newly admitted resident who had recently been hospitalized for an acute subdural hematoma did not receive a summary of the initial Baseline Care Plan (BCP) within 48 hours of admission. Although the BCP was developed and entered into the medical record, there was no evidence it was shared with the resident, who expressed concern about not receiving information on their diet and swallowing plan. Staff interviews confirmed the BCP was not presented as required.
Surveyors identified that two residents did not have comprehensive, individualized care plans addressing their specific needs, including incomplete documentation for medical conditions and delayed care planning for transfer assistance after a fall. Facility staff confirmed that care plans were either incomplete or not developed in a timely manner.
The facility did not hold care plan meetings after comprehensive assessments for two residents and failed to invite them to participate, with only their guardians being contacted. Documentation was lacking for both the meetings and the rationale for not including the residents.
A resident with significant medical and cognitive needs, confined to their room, was observed multiple times without engagement in meaningful activities, despite a care plan indicating the need for personalized interventions. Documentation revealed only three one-to-one activity visits over two months, and staff acknowledged the lack of ongoing, individualized activities for this resident.
A resident experienced decreased vision and was scheduled for a follow-up with an eye specialist, but there was no documentation that the appointment occurred. Interviews revealed that Medical Records staff, responsible for scheduling and transportation, were unaware of the appointment, resulting in the missed follow-up.
A resident with limited mobility and contractures did not receive prescribed knee extension braces and hand splints as ordered, and there was no documentation of their application. The DON confirmed that the orders were not transferred to the TAR, resulting in a lack of evidence that the treatments were provided.
A resident with involuntary lower extremity movement and poor spatial awareness was not provided with a perimeter mattress as required by their care plan after a room change. The omission was confirmed through observation and staff interviews, and the resident experienced two falls from bed in the new room where the mattress was not in place.
A resident with neuropathic pain was readmitted from the hospital, and although hospital discharge instructions recommended continuing gabapentin, the medication was discontinued on the day of readmission. The NP's progress note initially indicated gabapentin should be continued, but there was no documentation or rationale for its discontinuation, and the NP later could not recall the reason for stopping the medication.
A resident with shortness of breath did not receive an additional 40 mg dose of furosemide as recommended by the provider. The medication was not documented as given, and staff could not provide evidence or a rationale for the omission. The DON confirmed that the nurse did not follow expected documentation practices.
A resident's medication regimen review reports completed by the pharmacist were not included in the medical record, and there was no process to ensure the primary care provider's review and documentation of actions taken. Staff interviews confirmed that while reports were reviewed and signed by the NP, they were not consistently filed in the resident's record, and the DON had to retrieve them from the pharmacist.
A surveyor found an unattended and unlocked medication cart in a hallway, with multiple drawers containing medications accessible. A nurse, who was responsible for the cart and managing two carts due to staff absence, confirmed the cart should have been locked and stated it was left open by accident.
A surveyor observed a significant buildup of plastic bags, leaves, pine needles, and plastic cups behind the dumpster used by kitchen staff, indicating improper disposal and maintenance of the outdoor garbage area. The Director of Maintenance confirmed that this accumulation should not be present.
Surveyors found that clean clothing belonging to residents who were hospitalized or had expired was stored in green bags within the dirty laundry room. The Environmental Director confirmed the clothes were clean, and the DON was notified of the risk for accidental contamination due to this storage practice, which did not minimize the potential spread of infection.
The facility failed to report several incidents of alleged abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. Incidents included a resident being threatened by a GNA, another resident alleging being hit, and a case of missing money. Additionally, an LPN allegedly yelled at a resident and refused to change a wound dressing, and an injury of unknown source was not reported promptly. The NHA confirmed delays in reporting and acknowledged staff education on timely reporting.
The facility failed to accurately code MDS assessments for four residents, missing documentation of falls, injections, surgeries, and required assessments for cognitive patterns, mood, and pain. Staff confirmed these errors during interviews.
A resident experienced chest pain that was not addressed by facility staff until the family intervened. The resident reported chest pain since the morning, but staff did not notify the physician or document the issue until late afternoon. Nitrostat was offered but refused, and the family requested ER evaluation. The NHA confirmed the lack of timely physician notification.
The facility failed to thoroughly investigate abuse allegations involving two residents. A resident's family member accused others of abuse, and the resident reported disrespectful and abusive behavior, including exposure by another resident. The investigation lacked statements from involved parties and witnesses, and the administrator confirmed the investigation was incomplete.
Facility staff failed to adhere to and update the care plan for a cognitively impaired resident with poor safety awareness. The resident, who had a history of falls, was observed without a required safety helmet, non-skid socks, and hip protectors, contrary to the care plan. The care plan had not been reviewed or revised following the resident's latest assessment, as confirmed by the DON.
A resident, dependent on staff for bathing, received inadequate assistance with activities of daily living, as only three showers were documented during an eight-week stay. The MDS assessment confirmed the resident's total dependence on staff for bathing, but the facility failed to provide the necessary care, as confirmed by the DON.
A facility failed to conduct required neuro checks for a resident after a fall, despite initial assessment showing a slight hematoma on the forehead. The protocol required frequent neuro checks following an unwitnessed fall or head injury, but no further checks were documented after the initial assessment. The ADON confirmed the lapse in following the protocol, leading to a deficiency in meeting the resident's health needs.
A resident with multiple wounds did not receive timely treatment for pressure ulcers upon admission and after returning from the hospital. Initial treatment for a stage II ulcer was delayed by a week, and a stage III ulcer was not treated until four days after documentation. Additional wounds were also left untreated for several days. The DON confirmed the lack of documentation and expected procedures were not followed.
A resident experienced significant weight loss due to the facility staff's failure to timely assess and evaluate nutritional needs. The resident's weight dropped from 285.1 pounds at admission to 252.4 pounds, with the staff failing to recognize and address the weight loss promptly. The DON confirmed the oversight in timely intervention.
A resident with seborrheic dermatitis was found to have three active orders for medicated shampoos, despite a dermatology consult indicating only one was necessary. The facility staff failed to ensure the resident's medication regimen was free from unnecessary drugs, as the resident was receiving Selsun Blue, Ketoconazole, and Ciclopirox shampoos concurrently.
A resident with urinary retention and poor ambulatory status attended a urology consultation, where a follow-up procedure was recommended. However, the resident was discharged without a follow-up appointment being scheduled. This oversight was confirmed by the DON.
The facility failed to maintain accurate medical records and medication documentation for two residents. One resident, who was cognitively impaired, had inconsistencies in the documentation regarding the use of a Wanderguard bracelet, while another resident's Medication Administration Record (MAR) showed blank entries for several medications, indicating a failure to document administration. Interviews with nursing staff confirmed expectations for proper documentation were not met.
Failure to Document Assessments and Timely Wound Care Interventions
Penalty
Summary
Surveyors identified deficiencies related to the facility's failure to accurately document assessments and ensure residents received treatment and care in accordance with professional standards. For one resident, Nitroglycerin was administered on multiple occasions without documentation of symptoms or assessments prior to administration. Interviews with the DON and an LPN confirmed that any change in condition, such as chest pain, should be documented in the electronic medical record, and that all steps taken in response to unusual symptoms should be recorded. However, the medical record lacked this required documentation. Another resident was found to have inconsistencies in skin assessment documentation within 24 hours of readmission. The admitting nurse documented intact skin, while subsequent assessments by the wound care nurse and nurse practitioner identified a stage 3 pressure ulcer and Moisture Associated Skin Damage (MASD) on the left buttock. The wound care nurse later explained that there was a user error in documentation, resulting in inaccurate records. Additionally, there was no evidence that the facility notified the resident's primary care practitioner of the wound upon readmission or that wound care treatment was initiated at that time, despite recommendations from the nurse practitioner. Wound care orders were not implemented until several days after readmission. Review of the GNA flowsheet and interviews with staff revealed further discrepancies, as documentation indicated no skin impairment for several days, despite clinical notes to the contrary. The facility's process for admission and wound care assessment was described by staff, but the records showed that required assessments and timely interventions were not consistently completed or documented. The DON confirmed that the hospital discharge summary did not indicate a wound, yet the resident developed significant skin impairment shortly after readmission, with delayed initiation of appropriate wound care.
Failure to Assess and Document Behavioral Health Needs
Penalty
Summary
The facility failed to assess or document the behaviors of a resident diagnosed with dementia with behavioral disturbance. Despite the resident exhibiting worsening agitation, wandering, and behaviors such as entering other residents' rooms and touching their belongings, there was no documentation or behavior monitoring order in the medical record. The resident was prescribed medications for behavioral health needs upon admission, but the facility did not implement or record any behavior monitoring as required. Interviews with facility staff revealed that information about the resident's behavioral issues was communicated verbally rather than documented. The Psychiatric Nurse Practitioner confirmed awareness of the resident's aggressive behaviors through verbal reports only, and the DON acknowledged that behavior monitoring should have been documented in the Treatment Administration Record. Upon review, the DON verified the absence of any assessment or documentation of the resident's behaviors in the medical record.
Failure to Maintain Audible Call Bell System in Resident Areas
Penalty
Summary
The facility failed to maintain a fully functioning call bell system on the second floor, as evidenced by the lack of an audible call bell sound in the hallways and at the nurses' station. During the survey, the call bell light was observed to be on outside a resident's room, but no audible alert was heard by staff in the area. Staff confirmed that they did not hear any call bell sound, and the Maintenance Director later acknowledged that the sound on the second floor was significantly lower than on the first floor. The issue had not been previously reported to maintenance, and the problem was identified as new, with the last inspection showing no issues. A resident with a tracheostomy reported that they had called for a nurse to assist with suctioning and experienced long wait times for call bell responses, sometimes up to an hour. The surveyor observed staff present at the nurses' station who did not respond to the call bell light, further indicating that the system was not functioning as intended to alert staff to resident needs. The deficiency was identified through complaint review, direct observation, and staff and resident interviews.
Failure to Protect Resident from Verbal Abuse and Inadequate Investigation
Penalty
Summary
Facility staff failed to ensure that a resident was free from verbal abuse, as evidenced by an incident involving a resident with legal blindness who reported being verbally abused by a Geriatric Nursing Assistant (GNA). The resident stated that after waiting over two hours for assistance to use the bathroom, an argument ensued during which the GNA called the resident a derogatory name related to their blindness. The resident's roommate was present during the incident. The Social Service Director confirmed that neither the resident nor their roommate had a history of fabricating complaints or causing trouble. The facility's investigation into the incident was insufficient. The Administrator relied on staff and resident questionnaires, but did not conduct or document thorough interviews with the alleged victim, witnesses, or staff involved. Although another resident also indicated awareness of abuse, there was no documentation of follow-up to clarify this response. The Administrator acknowledged that interviews were not properly documented and was unable to provide evidence supporting staff denials of the abuse allegation.
Delayed Reporting of Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency (SA) within the required two-hour timeframe after discovering the incident. Record review showed that the facility became aware of a resident's injury at 7:20 AM and did not report it to the SA until 11:02 AM, resulting in a delay of approximately 3 hours and 42 minutes. This delay exceeded the regulatory requirement for timely reporting of such incidents. The deficiency was identified during a complaint survey and was confirmed through review of the facility's investigation packet and interviews with facility staff.
Failure to Conduct Thorough Investigations of Alleged Violations
Penalty
Summary
Facility staff failed to conduct thorough investigations into alleged violations involving two residents. In the first case, an email complaint was received by the Administrator and DON detailing concerns about a resident's care, including issues with medications, oxygen, nutrition, hydration, hygiene, and personal care. The investigation file was missing the original complaint email, and when it was later provided, it was found that not all concerns listed by the complainant were addressed in the facility's investigation. Documentation showed significant gaps in incontinence care, with records indicating the resident may have gone over 12 hours without being changed on multiple occasions. The facility was unable to provide additional documentation to confirm that care was provided more frequently than recorded, and did not investigate all concerns raised, such as those related to medication and oxygen. In the second case, a resident reported to the Social Service Director that a GNA was verbally aggressive during a specific shift. The investigation file indicated that interviews were conducted, but there was no documentation of these interviews except for the alleged perpetrator. Staff and resident questionnaires were used, but responses indicating possible abuse were not followed up as required. The resident involved, who is legally blind, described a delay in assistance and reported being verbally abused by the GNA, with a roommate present as a witness. The facility's investigation did not include documented interviews with all relevant staff, witnesses, or the alleged victim, and the Administrator acknowledged that interviews were not properly documented. In both cases, the facility's investigations were incomplete, lacking documentation and follow-up on all allegations and failing to address all concerns raised by complainants. The absence of thorough documentation and failure to investigate all aspects of the complaints led to inconclusive findings and unaddressed allegations regarding resident care and staff conduct.
Failure to Provide and Document Required ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide adequate care and assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene and incontinence care. The deficiency was identified when it was found that the resident was left unbathed and soiled with urine and bowel movement on multiple occasions, as reported by a complainant. Documentation review revealed that the resident was scheduled to receive showers twice weekly, but records showed only two bed baths documented for the entire month when there should have been nine entries. Additionally, there were significant gaps in the documentation of incontinence care, with long periods between recorded care events. Interviews with facility staff, including a Geriatric Nursing Assistant (GNA) and the Assistant Director of Nursing (ADON), confirmed that staff are required to document showers, refusals, and incontinence care in both electronic records and shower logbooks, and to notify nursing staff of any refusals. However, the facility was unable to provide documentation verifying that the resident received the required care as scheduled. The lack of documentation and the observations of the resident being left soiled indicate that the facility did not ensure consistent provision and recording of necessary ADL and incontinence care for the resident.
Failure to Prevent Pressure Injury Under Orthopedic Device
Penalty
Summary
A deficiency was identified when a resident developed a pressure injury on the right lateral knee, attributed to the use of a knee brace. The resident had an order to wear a right hinge-knee brace locked in extension at all times, with no range of motion allowed. Although there was an initial order to assess the skin under the brace and report abnormalities, this order was discontinued after a few days, and no further documentation of skin assessments was found in the progress notes or treatment administration record for over a month. The care plan included an intervention to check the right knee skin under the immobilizer every shift and notify the medical provider of any abnormalities, but there was no evidence that this intervention was consistently implemented during the period in question. Staff interviews revealed that the standard practice was to assess the skin before and after placement of orthopedic devices, ideally every two to four hours, regardless of whether there was a specific order. However, in this case, the lack of documented skin checks and the absence of ongoing assessment orders contributed to the development of an avoidable pressure injury. The wound was first identified during a skin and wound evaluation, at which point recommendations were made to check the skin daily, consult orthopedics, and consider alternative bracing or additional padding.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when a facility failed to implement fall prevention interventions for a resident who had experienced multiple falls and was assessed as high risk for falls. The resident's care plan included specific interventions such as frequent rounding, bilateral fall mats, and ensuring a call pad was within reach and placed on the side of the bed where the resident was most likely to fall. Despite these documented interventions, observations by the surveyor on two separate occasions revealed that the call pad was not within the resident's reach and was not positioned on the correct side of the bed, as required by the care plan. Instead, the call pad was found on top of a suctioning container and, at another time, on top of an oxygen humidifier machine. Interviews with the resident's representative and facility staff, including the ADON, confirmed that the call pad was not consistently placed according to the care plan. The resident's representative provided photographic evidence of the improper placement, and the ADON acknowledged that the required interventions were not in place at the time of the observations. The administrator and DON were notified of these concerns regarding the lack of adherence to fall prevention measures for the resident.
Failure to Accurately Document Toileting Hygiene After Incontinent Episodes
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, as evidenced by discrepancies in documentation related to toileting hygiene following incontinent episodes. Specifically, the resident experienced bladder and bowel incontinence on several occasions during the night shift, but the Geriatric Nursing Assistant (GNA) documented 'Not Applicable' (NA) for the Toileting Hygiene task instead of indicating whether care was provided or refused. The Director of Nursing (DON) confirmed that the expectation is for GNAs to document if care was provided or if the resident refused care, using the 'Resident Refused' (RR) option when applicable. During interviews, the GNA responsible for the documentation stated that 'NA' was used when a task did not apply, but in this case, the GNA intended to document a refusal but was unable to do so and therefore selected 'NA.' This resulted in incomplete and inaccurate records regarding the resident's care after incontinent episodes, as the documentation did not accurately reflect whether hygiene care was provided or refused by the resident.
Improper Food Storage and Labeling Practices Identified
Penalty
Summary
Facility staff failed to properly store food in accordance with professional standards for food service and safety. During a kitchen inspection, surveyors observed two containers of cottage cheese in the refrigerator, both labeled with received and sell-by dates, and a small block of lunch meat labeled only with an opened and use-by date, but lacking product identification. Additionally, a package of hot dogs was found unsecured and open to air. In the freezer, a water bottle containing a dark liquid was present without a label, and a cut of meat was stored in a pan with cellophane that was not airtight, resulting in visible freezer burn. In the dry storage area, opened packages of ziti and long pasta were found without labels indicating when they were opened or when they should be used by. On a separate unit, the 2nd floor nourishment refrigerator was inspected and found to contain two plastic bags of deli meats. One bag was labeled with a resident room number, but the other lacked any label or date, making it unclear who it belonged to or how long it had been stored. Staff confirmed that only staff had access to the refrigerator and acknowledged that the unlabeled bag should have been properly identified and dated.
Inaccurate Documentation of Resident Assessments
Penalty
Summary
The facility failed to accurately document assessments in the medical records of two residents. For one resident, the Minimum Data Set (MDS) assessment recorded only one stage 3 pressure ulcer, while a prior wound nurse note documented both a stage 3 sacral wound and a stage 2 left hip wound upon readmission. The discrepancy was confirmed during an interview with MDS staff, who acknowledged the error in documentation. For another resident, the MDS discharge assessment indicated a transfer to a short-term general hospital, but the discharge summary stated the resident was stable and discharged home with a spouse. This inconsistency was also confirmed by MDS staff, who stated the discharge location was documented in error.
Failure to Provide Baseline Care Plan Summary to New Admission
Penalty
Summary
The facility failed to inform a newly admitted resident of a summary of the initial Baseline Care Plan (BCP) within 48 hours of admission, as required. The BCP, which should include essential healthcare information to address immediate needs and reduce the risk of negative outcomes, was developed and entered into the medical record, but there was no evidence that the summary was shared or provided to the resident. The resident, who had recently been hospitalized for an acute subdural hematoma, expressed concern about not receiving information regarding their diet and swallowing plan of care. Interviews with staff revealed that the assigned social worker was a new hire and had only documented discharge planning, with no documentation of the BCP being presented to the resident. The Director of Nursing confirmed that the BCP was not shared as expected.
Failure to Develop Comprehensive, Person-Centered Care Plans for Residents at Risk for Falls
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents reviewed for falls. For one resident, the care plans initiated were incomplete and did not specify the reasons for the interventions, such as oral/dental health problems, use of anti-psychotic and anti-depressant medications, risk for respiratory complications, and the presence of an automatic implanted cardiac defibrillator. The care plans lacked individualized details and did not address the specific needs of the resident, as confirmed by the Director of Nursing during an interview. For another resident, there was a delay in developing a care plan related to transfer assistance following a fall that occurred while using a sliding board. Although the resident was initially deemed safe to use the sliding board independently with supervision, a re-evaluation later determined that one staff assist was required for transfers. The care plan reflecting this change was not developed until after the fall, and both the Director of Rehabilitation and the Unit Manager acknowledged that the care plan should have been created earlier.
Failure to Conduct Timely Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct care plan meetings following each comprehensive assessment and did not invite residents to participate in their care plan meetings. Specifically, for two out of four residents reviewed, there was no evidence that care plan meetings were held after their Minimum Data Set (MDS) assessments, nor was there documentation explaining why the residents were not invited to participate. In one case, a resident reported not being invited to a care plan meeting for an extended period, and attendance records confirmed the absence of the resident at previous meetings, with only the guardian participating via telephone. Further review of records showed that after the resident's MDS assessments, there were no attendance logs or documentation of care plan meetings being conducted. The Director of Social Services confirmed that no care plan meetings were held after the specified assessments and could not provide documentation for the lack of resident participation. This failure to conduct timely care plan meetings and involve residents as required was evident in the reviewed cases.
Failure to Provide Ongoing Personalized Activities for Room-Bound Resident
Penalty
Summary
A deficiency was identified when a resident, who was confined to their room due to a recent cerebral infarction resulting in a new tracheostomy and feeding tube, was observed on multiple occasions lying in bed, staring at the walls, and falling asleep without any activity staff present or nearby. The resident had a history of diabetes mellitus and depression, and their care plan indicated a need for more personalized activities due to a new low cognitive baseline and several chronic disease processes. Despite this, documentation showed that the resident received only three one-to-one activity visits over a two-month period. Interviews with the Activity Director confirmed that residents unable to participate in group or social activities were supposed to receive frequent, meaningful, ongoing personalized activities. However, after reviewing the activity records, the Activity Director acknowledged that there was a lack of meaningful one-to-one activities provided to this resident. The Director of Nursing was also made aware of this deficit in meeting the resident's needs for personalized activities.
Failure to Ensure Resident Attended Scheduled Eye Specialist Appointment
Penalty
Summary
A deficiency was identified when a resident reported decreased vision since admission, and a review of their medical records showed a missed follow-up appointment with an eye specialist. The resident was scheduled for an eye appointment, as documented in a progress note, but there was no evidence that the appointment occurred. Interviews with facility staff revealed that the Medical Records department was responsible for scheduling follow-up appointments and transportation, but the staff member in charge was unaware of the scheduled eye appointment. The Administrator confirmed the lack of documentation regarding the resident's attendance at the appointment.
Failure to Provide and Document Prescribed ROM Devices
Penalty
Summary
A deficiency was identified when a resident with limited mobility and a history of contractures was not provided with the prescribed treatments to maintain or improve range of motion. The resident had physician orders for bilateral knee extension braces to be worn for six hours daily as tolerated, and for resting hand splints to be applied to both hands for up to two hours at a time after hand hygiene. Multiple observations by the surveyor revealed that the resident was not wearing the prescribed braces or splints, and the resident was consistently seen with knees pulled to the chest and contracted fingers. A review of the resident's medical record showed no documentation that the splints or braces were applied as ordered. During interviews, the DON confirmed that the use of braces and splints should be documented, but acknowledged that the orders for these treatments were never transferred to the Treatment Administration Record (TAR), resulting in a lack of documentation and evidence that the treatments were provided as prescribed.
Failure to Provide Care Planned Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a necessary intervention for a resident identified as a fall risk. The resident had a care plan in place due to involuntary movement of both lower extremities and unawareness of personal boundaries, which included the use of a perimeter mattress for spatial awareness and border definition. After the resident was moved to a new room, the perimeter mattress was not provided, despite being listed as a required intervention in the care plan. Observations confirmed the absence of the perimeter mattress, and staff interviews revealed uncertainty about why the mattress did not transfer with the resident. The resident experienced two documented falls from bed in the new room where the perimeter mattress was not in use. The spouse of the resident reported multiple falls and noted that the special mattress had previously helped keep the resident in bed. The Director of Nursing confirmed the resident was not provided with the perimeter mattress as care planned and was unaware of the reason for this omission. The deficiency was identified through observations, staff interviews, and review of the resident's medical record and fall history.
Failure to Accurately Review and Prescribe Medications After Resident Readmission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a medical provider thoroughly reviewed and accurately prescribed medications following a resident's readmission from the hospital. The resident, who had a history of neuropathic pain, was readmitted on the same day that their gabapentin order was discontinued. Hospital discharge paperwork recommended continuing gabapentin for neuropathic pain, but the medication was not listed among those to be continued, discontinued, or newly started. Upon readmission, the nurse practitioner's progress note indicated gabapentin should be continued, but there was no subsequent documentation or rationale for discontinuing the medication. Further review revealed that the nurse practitioner could not recall the reason for discontinuing gabapentin and stated that the resident did not report pain during assessment, nor was there any communication about uncontrolled pain. The omission of gabapentin was later identified as a missed order, but at the time of the deficiency, the medication was not provided as recommended in the hospital discharge instructions and as indicated in the provider's initial progress note.
Failure to Administer Ordered Medication and Document Administration
Penalty
Summary
A deficiency occurred when a resident experiencing shortness of breath did not receive an additional 40 mg dose of furosemide as recommended by the provider. The recommendation was documented in an SBAR note, but a review of the medication administration record showed no evidence that the medication was administered. When requested, facility staff were unable to provide documentation or a rationale for the omission. Interviews with the Administrator and DON confirmed that the medication was not given and that the nurse responsible did not follow the facility's expected practice for documenting administered medications.
Failure to Document and Track Medication Irregularity Reports in Resident Record
Penalty
Summary
The facility failed to ensure that a process was in place for medication irregularity reports generated by the pharmacist to be reviewed by the primary care physician and for the actions taken based on those recommendations to be documented in the resident's medical record. Specifically, for one resident, pharmacy medication regimen reviews were completed on three separate occasions, but the corresponding reports were not found in the resident's electronic medical record. The Director of Nursing (DON) had to obtain these reports directly from the pharmacist, indicating they were not properly filed or accessible as part of the resident's official record. Interviews with facility staff revealed that the process involved the DON or a nurse printing the pharmacist's reports and providing them to the nurse practitioner (NP) for review. The NP would review, document decisions, and sign the reports before returning them to the DON or nurse for implementation of any indicated orders. However, there was no clear process for ensuring that these reports and the responses to them were incorporated into the resident's medical record, as confirmed by both the NP and the DON.
Unsecured Medication Cart Found Unlocked in Hallway
Penalty
Summary
A surveyor observed an unlocked medication cart in the hallway between two resident rooms during a random observation on the second floor. The surveyor was able to open the top drawer and found multiple medications and supplies, as well as access all seven other drawers containing medications. Staff confirmed that the cart was the responsibility of a nurse who was working with two medication carts due to a Certified Medication Aide calling out sick and a subsequent reassignment of duties. The nurse acknowledged that the cart should not have been left open and stated it was left unlocked by accident.
Improper Maintenance of Outdoor Garbage Storage Area
Penalty
Summary
The facility failed to maintain the outdoor garbage storage area in a sanitary manner to prevent the harboring of pests. During an observation, a surveyor noted a significant accumulation of plastic bags, leaves, pine needles, and plastic cups, approximately six inches high, located between the dumpster and the concrete wall behind it. This accumulation was found in the area used by kitchen staff for garbage disposal, just outside the kitchen receiving doors. In an interview, the Director of Maintenance acknowledged that the accumulation should not be present in that area.
Improper Storage of Clean Resident Clothing in Laundry Room
Penalty
Summary
During the recertification survey's infection control investigation, surveyors observed six green bags containing clean clothes stored in the facility's dirty laundry room. Staff interviews confirmed that these clothes belonged to residents who were either hospitalized or had expired. The Environmental Director acknowledged that the clothes in the bags were clean, and the Director of Nursing was informed of the potential risk for accidental contamination due to the storage method. The facility failed to ensure that clean residents' clothing was stored in a manner that minimized the potential spread of infection, as required by infection prevention and control protocols.
Delayed Reporting of Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report several incidents of alleged abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. In one instance, a resident reported being threatened by a geriatric nursing assistant at 3:00 AM, but the report was not submitted to OHCQ until 9:27 AM. The Nursing Home Administrator (NHA) confirmed the delay, stating he reported it as soon as he became aware. Another incident involved a resident who alleged being hit in the back, but the staff failed to report this to the NHA immediately, resulting in a delayed report to OHCQ. In another case, a resident reported being abused by staff members, but the allegation was not reported until several days later. The NHA confirmed that the staff involved were educated on timely reporting, but the delay in reporting was acknowledged. Additionally, an incident involving a Licensed Practical Nurse (LPN) allegedly yelling at a resident and refusing to change a wound dressing was not reported to the NHA until nearly two weeks later. The NHA noted that the staff involved were reprimanded for failing to report the incident promptly. Further deficiencies were noted in the reporting of a misappropriation of property, where a resident reported missing money, but the facility did not report the allegation to the state agency within the required timeframe. Similarly, an injury of unknown source was observed on a resident, but the report to the state agency was delayed. The NHA was unable to recall the exact timeline of events for this incident, indicating uncertainty about the reasons for the delay in reporting.
Inaccurate MDS Assessments and Documentation Failures
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for four residents during a complaint survey. For Resident #36, the facility did not document multiple falls that occurred on specific dates, nor did they capture an injection that was administered. The errors were confirmed by MDS coordinators during an interview. Resident #37's medical record review revealed that the facility did not capture a fall that occurred at home prior to admission, nor did they document a major surgery that the resident underwent during a hospital stay. The error was acknowledged by Staff #10, who admitted to forgetting to ask the resident about the fall. For Resident #42, the facility failed to conduct and document required assessments for cognitive patterns, mood, and pain, despite indications that these assessments should have been conducted. Additionally, a fall was not captured in the MDS. Staff #11 confirmed these omissions and noted issues with social work completing the MDS on time. Resident #34 also had a fall that was not documented in the MDS, as confirmed by Staff #11 and the Assistant Director of Nursing.
Failure to Promptly Notify Physician of Resident's Chest Pain
Penalty
Summary
The facility staff failed to promptly notify the physician of a resident's change in condition, specifically regarding chest pain. The resident, admitted in August 2023 for rehabilitation due to debility, reported experiencing chest pain since 10:00 AM on September 2, 2023. However, the staff did not address the complaint until the resident's family arrived at the facility at 4:40 PM and insisted on calling 911. The nursing notes documented the chest pain at 5:56 PM, and although Nitrostat was offered to the resident, it was refused. The responsible party requested the resident be transferred to the ER for evaluation. The Nursing Home Administrator (NHA) and the previous Director of Nursing (DON) acknowledged the delay in addressing the resident's chest pain. The primary nurse, Staff #45, claimed to have been informed of the chest pain at 3:50 PM and offered Nitrostat, but there was no documentation of physician notification at that time. The grievance report provided to the surveyor lacked an attached statement, and the NHA confirmed the absence of documentation supporting timely physician notification.
Incomplete Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving two residents during a complaint survey. In one incident, a family member of a resident accused other residents of abusing their relative. The resident's medical record indicated that a psychologist documented the resident's claim that another resident had been disrespectful and verbally abusive. The resident also alleged that another resident had exposed themselves in the doorway. However, the facility's investigation did not include a statement from the resident who made the allegations, nor from the resident accused of the behavior, or any staff who might have witnessed the event. The surveyor's review revealed that the facility's investigation was incomplete, as it did not address the allegations made by the resident to the psychologist. The administrator confirmed that the facility staff did not conduct a thorough investigation into the allegations of abuse. This deficiency was evident in two out of fifty facility-reported incidents reviewed during the survey.
Failure to Follow and Update Resident Care Plan
Penalty
Summary
The facility staff failed to follow and update the care plan for a resident who was cognitively impaired and independently ambulatory with poor safety awareness. The resident had an unwitnessed fall resulting in a laceration and swelling above the right eye. The care plan, initiated after the incident, required the resident to wear a safety helmet when out of bed. However, during an observation, the resident was seen sitting in a chair without the helmet, indicating non-compliance with the care plan. Additionally, the care plan included interventions for the resident to wear non-skid socks and hip protectors at all times, except during care. During the same observation, the resident was not wearing the required non-skid socks or hip protectors. The medical record review showed no documentation that the care plan had been reviewed or revised following the resident's most recent quarterly assessment. These failures were confirmed by the Director of Nurses during the survey.
Failure to Provide Adequate Assistance with Activities of Daily Living
Penalty
Summary
The facility staff failed to provide necessary activities of daily living for a resident who was dependent on assistance with personal care. The deficiency was identified during a complaint survey, where it was found that a resident, admitted in August 2022 and discharged in October 2022, only received three documented showers during their eight-week stay. The resident's MDS assessment indicated total dependence on staff for bathing. However, documentation showed showers were only provided on three occasions, with no additional records found in the nursing notes. The Director of Nursing confirmed the lack of documentation for additional showers, corroborating the complaint that the resident received only two showers in a six-week period.
Failure to Conduct Neuro Checks After Resident Fall
Penalty
Summary
The facility failed to provide adequate care for Resident #27 following a fall, as evidenced by the lack of documented neuro checks after the initial assessment. On 1/20/23, Resident #27 was found on the floor beside their wheelchair with a slight hematoma on the forehead after attempting to transfer themselves to bed. A comprehensive multisystem assessment was completed, and neuro checks were initiated with normal results initially. However, no further neuro checks were documented in the medical record, despite the physician's orders to continue monitoring and report any abnormalities. An interview with the Assistant Director of Nursing (ADON) confirmed that the facility staff did not complete the required neuro checks as per the protocol for unwitnessed falls or head injuries. The ADON stated that the protocol required an initial neuro check followed by checks every 15 minutes for the first hour, every 30 minutes for the next hour, every hour for four hours, and then every shift for 24 hours. The failure to adhere to this protocol resulted in a deficiency in meeting the resident's physical, mental, and psychosocial health needs.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely treatment and services to prevent and heal pressure ulcers for a resident admitted with multiple wounds. Upon admission in May 2023, the resident had a healing wound above the sacrum and a pressure ulcer near the left inner thigh. A subsequent note documented a stage II pressure ulcer on the buttock, but treatment for this ulcer was not initiated until a week later, on May 17, 2023. The resident was discharged to the hospital on May 29, 2023, and upon return on June 2, 2023, refused assessment. By June 6, 2023, a stage III pressure ulcer was documented on the left buttock, yet no treatment was recorded until June 7, 2023. Further review revealed that upon the resident's return from the hospital on June 16, 2023, there were additional wounds on the right and left buttocks and a suspected deep tissue injury on the right heel. However, treatment for these wounds was not documented until June 21, 2023. The Director of Nursing confirmed the lack of documentation and stated that the expectation was for the charge nurse to assess the resident upon admission, notify the physician, and obtain orders for immediate treatment, which was not done in this case.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility staff failed to assess and evaluate the nutritional needs of a resident in a timely manner, leading to significant weight loss. Upon admission, the resident's weight was documented as 285.1 pounds, and a nutritional assessment was completed three days later, setting goals to maintain nutritional status and consume at least 50% of meals and supplements daily. However, the resident was not reweighed until 15 days after admission, showing a weight loss of 6.4 pounds. By December 2, the resident's weight had dropped to 252.4 pounds, indicating a total weight loss of 32.7 pounds since admission. The facility staff did not recognize the weight loss documented on November 16 and December 2 until December 7, and failed to reweigh the resident in a timely manner after the weight loss was identified. The resident was not reweighed until December 16, 14 days after the dietitian's note, at which point the weight was documented as 270 pounds. The Director of Nursing confirmed that the facility staff failed to recognize and intervene in the resident's weight loss in a timely manner.
Unnecessary Medication in Resident's Drug Regimen
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication. This was identified during a review of a complaint regarding a resident with seborrheic dermatitis, a common skin condition causing dandruff. The resident was initially prescribed Ketoconazole shampoo twice a week and had a dermatology appointment scheduled. Following the dermatology consultation, the physician prescribed Ciclopirox shampoo weekly and Derma smooth scalp oil for itching, with a follow-up in two months. However, a review of the resident's January 2025 Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed that there were three active orders for medicated shampoos being implemented to treat the resident's condition. These included Selsun Blue shampoo, Ketoconazole shampoo, and Ciclopirox shampoo, despite the dermatology consult indicating only Ciclopirox was necessary. The Director of Nurses (DON) was informed of the discrepancy and confirmed that only one medicated shampoo should have been ordered, as per the dermatologist's recommendation.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility staff failed to ensure a follow-up appointment with a consultant physician for a resident who was admitted with a diagnosis that included retention of urine. The resident, who had poor ambulatory status and required a wheelchair that could not clear doorways due to bariatric size, attended a urology consultation. The consulting physician recommended rescheduling at an ambulatory surgery center for a local cystoscopy and Foley catheter change. However, the resident was discharged home without a follow-up appointment being scheduled with urology. This deficiency was confirmed during an interview with the Director of Nursing.
Inaccurate Medical Records and Medication Documentation
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records for two residents during a complaint survey. For Resident #50, who was cognitively impaired and at risk for wandering, there was a discrepancy in the documentation regarding the use of a Wanderguard bracelet. The resident's medical record indicated that the Wanderguard was worn on various shifts, but there was no order for the device, and the resident was observed not wearing it. The Director of Nurses (DON) confirmed that the resident did not require a Wanderguard, highlighting inconsistencies in the documentation. For Resident #1, the facility failed to document the administration of several medications as required. The resident, who had a history of cerebral infarction and bipolar type schizoaffective disorder, had multiple medications listed in their Order Recap Report. However, the Medication Administration Record (MAR) for October 2024 showed blank entries for several medications on specific dates, indicating a failure to document whether the medications were administered. Interviews with the Assistant Director of Nursing (ADON) and the DON revealed that the expectation was for medications to be administered and documented as ordered. These deficiencies indicate a lack of adherence to professional standards in maintaining accurate medical records and ensuring the proper administration and documentation of medications. The discrepancies in documentation and failure to follow established protocols for medication administration and monitoring devices contributed to the identified deficiencies.
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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