Anchorage Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, Maryland.
- Location
- 105 Times Square, Salisbury, Maryland 21801
- CMS Provider Number
- 215339
- Inspections on file
- 20
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Anchorage Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including morbid obesity, DM II, Stage 5 CKD, prior CVA with left-sided weakness, dementia, and other comorbidities, experienced a significant weight loss of 7.9% in one month as documented in the EMR. Facility policy required immediate notification of the resident, the practitioner, and the resident’s representative for significant changes in condition, such as this weight loss. The EMR generated a significant weight change alert, but another staff member cleared the alert, and department managers and the resident’s physician were not promptly informed of the change, resulting in a failure to provide required notification.
A resident with multiple comorbidities and an order for weekly skin assessments developed a new open area under the left great toenail that was initially identified and reported, with wound care orders put in place. However, required follow-up assessment tools were not completed, weekly skin integrity reviews for several weeks documented either no skin issues or lacked any detailed assessment of the toe wound, and the care plan was not updated to address the non-pressure wound. Later, an RN found the toe swollen, red, warm, tender, with the toenail and surrounding skin detached and dark discoloration of the toes; a CRNP then assessed a full-thickness infected wound with exposed subcutaneous tissue and moderate serosanguineous drainage. The resident was transferred to the hospital, where the wound was associated with MRSA bacteremia and the resident subsequently underwent a left below-knee amputation.
The facility failed to maintain firmly secured handrails on two of four floors, despite a maintenance policy and a high-priority work order noting needed repairs. Surveyors observed long sections of hallway handrails on the second floor detached from the wall and additional unsecured and missing handrails on the third floor. A CMA and the Resident Council President reported the handrails had been unrepaired for several months and noted that some residents rely on them for safety. The Maintenance Director and NHA both acknowledged awareness of the problem, with the NHA citing delays in obtaining materials as a reason repairs had not been completed.
A resident with acute and chronic respiratory failure, OSA, and severe obesity was readmitted from the ED after severe hypoxia requiring BIPAP and aggressive diuresis. The facility physician documented the need for pulmonary follow-up and possible PFT and CPAP, and later stated he had communicated to nursing that the resident required a pulmonary test and CPAP. The resident’s care plan addressed altered respiratory status and OSA and directed staff to report abnormal findings and monitor vitals. However, due to miscommunication between the physician and nursing staff, no CPAP order was written or processed, despite facility policy requiring timely handling of physician orders. The resident’s cause of death was recorded as congestive heart failure.
A cognitively intact resident with an order for turning and repositioning every 2 hours for wound management had multiple missed entries on the TAR where the intervention was not signed as completed. The care plan required encouraging or assisting the resident to turn and reposition and ensuring this was done. The resident reported prior concerns about not being turned every 2 hours. An LPN and an RN stated they performed the turning and repositioning but forgot to document it, and the DON and Administrator confirmed that staff were expected to document treatments and interventions at the time of care.
A resident with an abnormally high WBC count and on an NPO diet was not properly monitored or reported when a change in condition and an incident occurred. The facility failed to notify the physician and resident representative, and did not document the events as required by policy.
A resident with swallowing difficulties and on an NPO diet was found with a grape ice pop in their mouth, but staff did not document a change in condition or monitor for aspiration. Additionally, an abnormally high WBC count was not addressed or followed up with appropriate documentation or assessment.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and representative after a significant change in condition, specifically a significant weight loss. The facility’s policy on Notification of Change in Condition requires informing the resident, consulting with the resident’s medical practitioner, and/or notifying the resident’s representative or authorized family member when there is a significant change in the resident’s physical, mental, or psychosocial condition, including deterioration in health or clinical complications. During a complaint survey, it was determined that this policy was not followed for one resident. The complaint alleged that this resident was not provided with quality of care, prompting review of administrative documents, a closed medical record, and staff interviews. The resident involved had multiple diagnoses, including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, prior stroke with left-sided weakness, polyneuropathy, anemia in chronic kidney disease, hyperlipidemia, dementia, Vitamin D deficiency, GERD, and arthritis due to Lyme disease. A BIMS score obtained earlier showed severe cognitive impairment (6/15). Review of the resident’s record showed a weight of 199.3 pounds in early December and 183.0–183.5 pounds in early January, representing a 7.9% (15.8-pound) weight loss in one month. The facility dietician stated that the electronic medical charting system generates alerts to department managers for significant changes in condition, and that significant weight loss is an alert item. The resident’s significant weight loss was identified and confirmed, but another staff member cleared the weight loss alert, and as a result, department managers and the resident’s physician were not immediately made aware of the significant change in condition, constituting the cited deficiency.
Failure to Assess and Monitor Non-Pressure Toe Wound Leading to Infection and Amputation
Penalty
Summary
The facility failed to provide updated non-pressure wound assessments and failed to identify and monitor a new wound on a resident’s left great toe, resulting in delayed treatment for an infected wound. The resident had multiple diagnoses including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, stroke with left-sided weakness, and dementia, and had a physician order for weekly skin assessments to be documented every Monday. On 12/30/2025, a staff member alerted the unit manager LPN to a 0.5 cm open area under the resident’s left great toenail; the LPN observed the wound, documented the change in condition, and notified the physician and family. The physician ordered lab work, a venous doppler, and dressing care with betadine wet-to-dry dressings every shift. An assessment form completed that morning triggered a skin change in condition and indicated that a Braden Observation tool, Pain Observation tool, and Skin Grid (Pressure and Non-Pressure) tool should be completed and placed in the record, but there was no evidence that any of these three assessment tools were completed. Subsequent documentation failed to reflect ongoing assessment or monitoring of the left great toe wound. The doppler results reported on 12/31/2025 showed mild peripheral vascular disease in the left lower extremity without occlusion. However, review of the January Weekly Skin Integrity Reviews revealed no mention of the left great toe wound’s status, including any measurements or descriptions, for several weeks. On 01/05/2026, an LPN documented there were no skin areas; on 01/12/2026, another LPN documented there were no skin areas since the last skin check; and on 01/19/2026, an RN documented there was a skin area but did not attach an assessment of the left great toe. During this period, the resident’s care plan, which had previously identified risk for skin integrity issues, was not updated and no new care plan was initiated related to the non-pressure wound of the left great toe first identified on 12/30/2025. On 01/26/2026, an RN documented that the resident’s left great toe was swollen, red, warm, and tender, with the toenail no longer attached and the surrounding skin off, and areas of dark discoloration around the left toes. The RN notified the skin and wound consultant CRNP, who assessed the wound the same day. The CRNP documented that neither the resident nor facility nursing staff knew when the left great toe wound first appeared or what caused it, and described the toe as having the toenail removed with a large sheet of skin peeled off the entire distal toe. The CRNP’s wound assessment identified cellulitis and a new full-thickness wound measuring 2.1 cm x 6 cm x 0.3 cm with exposed dermis and subcutaneous tissue, unattached wound edges, and moderate serosanguineous drainage, though the resident denied pain. The CRNP cleansed and dressed the wound in preparation for transfer to the hospital, where the resident was later admitted for MRSA bacteremia secondary to a left foot wound and ultimately underwent a left below-knee amputation.
Failure to Maintain Secure Handrails on Resident Hallways
Penalty
Summary
Surveyors identified a deficiency related to unsecured and missing handrails on two of the facility’s four floors. The facility’s own “Policy for Facilities Maintenance Program” dated 8/12/2025 stated its purpose was to ensure a well-structured preventative maintenance program to promote safety and functionality. A work order created on 1/18/2026 by the administrator documented that handrails on the second floor needed attention and were assigned a high priority. Despite this, observations on 2/17/2026 and 2/20/2026 showed approximately a twelve-foot section of handrails on the second floor detached and unsecured from the wall. Further observation on the third floor showed an additional approximately five-foot section of unsecured and missing handrails. A CMA reported in interview that the handrails had not been repaired for several months and described them as a safety hazard. The Resident Council President stated the facility was aware the handrails had not been repaired for several months and explained that some residents depend on securing their hands on the handrails for safety. The Maintenance Director reported noticing the inoperable handrails upon being hired on 1/23/2026 and confirmed the facility was aware the second- and third-floor handrails were not secured, without knowing why repairs had not been completed. The Nursing Home Administrator acknowledged awareness that the handrails needed repair and stated that the supplier was taking too long to deliver the materials.
Failure to Obtain CPAP Order After Hospital Readmission for Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician’s recommended respiratory treatment, specifically a CPAP, was ordered and implemented for a resident readmitted from the hospital. The facility’s policy on General Physician Services states that the attending physician is responsible for managing the resident’s medical care and that care is based on the physician’s orders, including treatments and services. The resident was admitted with diagnoses of acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and obesity, and was dependent on staff for ADLs but cognitively intact with a BIMS score of 15/15. Nursing documentation shortly after admission noted diminished lung sounds bilaterally and that the resident preferred the head of the bed elevated to avoid shortness of breath, though no shortness of breath or need for supplemental oxygen was recorded at that time. The facility physician documented that the resident had presented to the ED with shortness of breath, was severely hypoxic, required BIPAP and aggressive diuresis, and was later transitioned to nasal cannula. In that same note, the physician concluded that the resident needed follow-up with pulmonary for possible PFT and possible CPAP. The resident’s care plan identified altered respiratory status related to respiratory failure and obstructive sleep apnea and directed staff to report abnormal findings to medical providers and monitor vitals. During interviews, the physician stated that, after reviewing the medical record and communicating with nursing staff, he informed nursing that the resident required a pulmonary test and a CPAP, and acknowledged that an order for CPAP should have been issued. The DON also stated there was miscommunication regarding the order and that the physician did not write it, despite facility policy requiring physician orders to be addressed in a timely manner. The resident’s cause of death was documented as congestive heart failure.
Failure to Accurately Document Turning and Repositioning on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete documentation on the Treatment Administration Record (TAR) for a resident who was readmitted to the facility and was coded as cognitively intact on a quarterly MDS. The resident had an order in January for turning and repositioning every 2 hours for wound management. Review of the January TAR showed multiple instances where this ordered intervention was not signed as completed, specifically on 01/02/2026 at 4:00 AM and 6:00 AM, 01/06/2026 at 6:00 PM, 01/10/2026 at 6:00 PM, and 01/28/2026 at 6:00 PM. The resident’s care plan dated 02/01/2026 included interventions to encourage or assist the resident to turn and reposition and to ensure the resident was turned and repositioned. During interviews, the resident reported having concerns in the past about not being turned and repositioned every 2 hours, although they stated that this had improved. An LPN and an RN who provided care to the resident each stated that they did turn and reposition the resident every 2 hours during their shifts, but both acknowledged they forgot to document these interventions on the TAR, with the LPN attributing this to getting busy with another resident. The DON confirmed that staff did reposition the resident every 2 hours but did not sign the TAR, and stated that staff were expected to document when treatments or interventions were completed. The Administrator also stated that the expectation was to document at the time of care so it would not be missed.
Failure to Notify Physician and Resident Representative of Change in Condition and Incident
Penalty
Summary
The facility failed to notify the physician and the resident's representative of a significant change in condition and an incident that potentially required physician intervention. Specifically, a resident had an abnormally high white blood cell (WBC) count, which was not reported to the physician or the resident's representative, and no change of condition report was initiated. Additionally, the resident, who was on an NPO (nothing by mouth) diet due to difficulty swallowing, was found with a grape ice pop in hand and a large piece in the mouth. This incident was not documented as a change in condition or incident, and neither the physician, nurse practitioner, nor the resident representative was notified. A review of the facility's policies indicated that nurses are responsible for reviewing and reporting abnormal lab results and significant changes in condition to the appropriate parties, including the physician and resident representative. The Director of Nursing confirmed that these notifications and required documentation were not completed for the resident in question. The failure to follow established protocols for notification and documentation led to the deficiency identified during the complaint survey.
Failure to Address Abnormal Lab Result and Monitor NPO Resident After Oral Intake
Penalty
Summary
The facility failed to address an abnormal laboratory result and did not monitor a resident for signs of aspiration following an incident that may have required physician intervention. Specifically, a resident with a history of difficulty swallowing and who was on an NPO (nothing by mouth) diet was found with a grape ice pop in their hand and a large piece in their mouth. Despite this, there was no documentation of a change in the resident's condition or initiation of monitoring for aspiration. Additionally, the resident's medical record showed an abnormally high white blood cell (WBC) count, which is significant for identifying infection or inflammation, but the facility did not document any response to this abnormal result or a change in the resident's condition. The lack of documentation and monitoring occurred despite the resident's known risk factors and the presence of clinical indicators that warranted further assessment.
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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