Autumn Lake Healthcare At Homewood
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 6000 Bellona Avenue, Baltimore, Maryland 21212
- CMS Provider Number
- 215074
- Inspections on file
- 18
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Homewood during CMS and state inspections, most recent first.
A resident experienced a significant medication error when a nurse administered meropenem, a broad-spectrum carbapenem antibiotic, instead of the cefepime that had been ordered by the physician to treat a UTI. Review of a complaint and the medication administration audit confirmed that the resident received an antibiotic that was not prescribed, constituting a failure to follow the five rights of medication administration, specifically the right medication, although no adverse outcome was documented.
A resident with elevated liver enzymes had a physician order for a right upper quadrant ultrasound, but nursing staff did not complete the ordered test. Review of the medical record showed no ultrasound results, and the DON confirmed that the ordered diagnostic study was never carried out, resulting in a failure to follow the practitioner’s order for necessary testing.
The facility did not complete annual performance reviews for GNAs or provide regular, individualized in-service education based on those reviews. During a survey, it was found that none of the reviewed GNA employee files contained performance reviews, and the DON confirmed that these had not been done for some time, resulting in a lack of tailored training for staff.
Staff did not maintain a safe, clean, and comfortable environment, as evidenced by stained ceiling tiles, peeling paint and laminate, rusted equipment, missing toilet paper, and unpainted spackled walls. Multiple residents were observed using wheelchairs with torn or cracked vinyl armrests, exposing foam padding. The maintenance department was understaffed, with only one staff member and recent changes to the repair reporting system.
The facility did not report multiple allegations of abuse, neglect, and theft to the regulatory agency within the required timeframes. Incidents included residents alleging physical and verbal abuse by staff, missing narcotic medication, and theft of personal items. In several cases, the administration was not promptly informed, resulting in delayed reporting to OHCQ, and in some instances, there was no documentation of when reports were submitted.
The facility did not thoroughly investigate or document multiple allegations of abuse and misappropriation of property, including incidents involving physical abuse by a phlebotomist, missing money, rough handling by an agency GNA, missing narcotic medication, and threatening behavior by staff. Investigations were incomplete, lacking necessary interviews with staff, residents, and witnesses, and in some cases, documentation was missing entirely.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in care that was not individualized or consistent with documented directives.
Surveyors identified multiple environmental deficiencies, including mold growth on window blinds, air conditioning units, and ceiling tiles, as well as damaged base molding, missing toilet paper holders, and unsanitary shower rooms with broken tiles and soiled washcloths. Facility leadership and staff confirmed these conditions during the survey.
Facility staff did not consistently hold or document interdisciplinary care plan meetings with residents and their representatives following required assessments. Medical record reviews for multiple residents showed missing or insufficient documentation of care plan meetings after several MDS assessments, and staff interviews confirmed these omissions.
The facility did not ensure fall precautions were in place for a resident with a history of falls, as a required floor mat was not positioned correctly. A resident assessed as high risk for unsafe smoking was found with multiple lighters in their room, contrary to the care plan and facility policy. Additionally, two residents who required supervision while smoking were observed smoking unsupervised, with one not using a required smoking apron and both having smoking materials in their possession. Staff interviews confirmed these lapses in supervision and adherence to care plans.
The facility did not consistently provide timely medications to residents, resulting in missed doses of essential treatments such as nicotine patches, IV antibiotics, and blood pressure medications due to delays in reordering and pharmacy delivery. Additionally, narcotic and controlled substance counts were not consistently reconciled by two nurses at shift changes, as required, with multiple missing signatures documented in log binders across all medication carts.
Staff did not properly dispose of expired yogurt and spoiled tomatoes in the kitchen, and failed to maintain sanitary and safe storage conditions in the nourishment room, including a leaking ice machine, mold-like substances, dirty cabinets with inappropriate items, and excessive ice build-up in the freezer.
Staff failed to follow infection control protocols, including improper storage and labeling of personal care items, lack of PPE use during medication administration to a resident with a G-tube and foley catheter, and absence of required signage and orders for residents needing Enhanced Barrier or Contact Precautions. Mold and unsanitary conditions were observed in multiple areas, and staff interviews confirmed awareness of these issues.
Staff failed to notify two residents' representatives and a physician about significant changes in condition, including a BiPAP machine malfunction for a resident with chronic respiratory failure and a hospital transfer for a resident with dementia. In both cases, required notifications were either delayed or not documented, as confirmed by the DON.
A resident with bone cancer, while in pain and expressing distress, was subjected to verbal abuse by a staff member who made a disparaging remark in the presence of another staff member and the resident's family member, who was on the phone. The incident was confirmed by both the family member and the second staff member, and the facility's investigation verified that verbal abuse occurred.
A resident was not protected from the wrongful use of their belongings or money, as staff or facility management failed to safeguard personal property or funds, resulting in unauthorized use.
Surveyors identified that MDS assessments were inaccurately coded for three residents, including failures to document regular pain medication, anticonvulsant use, behavioral refusals, and opioid administration, despite clear evidence in medical records and care plans. These errors were confirmed by the MDS Coordinator through record review and staff interviews.
Surveyors identified incomplete and inaccurate medical record documentation for three residents, including a physician's erroneous medication entry, multiple blank spaces on a MAR making it unclear if medications were administered, and missing care plan meeting documentation that was not accessible to the interdisciplinary team.
Staff did not ensure that two residents had their call bell controls within reach, as both were found with the call bells on the floor and inaccessible. A GNA/CMA confirmed that the call lights should have been accessible but were not at the time of observation.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required. The facility did not facilitate or respect the formation and participation of these groups.
A resident was admitted without a baseline care plan (BLCP) being completed within the required 48-hour timeframe, and no summary or current medication list was provided to the resident or their representative. The DON was unable to locate the BLCP in the medical record and confirmed it was never completed.
Facility staff did not develop a care plan for a resident with an indwelling urinary catheter as required, despite physician orders and documentation in the MDS. Although the IDT agreed to create a care plan, none was implemented for approximately three months after admission, and the DON confirmed the delay when interviewed.
Two residents did not receive proper pain management due to incomplete pain assessments, lack of pain medication parameters, and failure to document or provide non-pharmacological interventions before administering PRN opioids. Staff administered stronger pain medications outside of prescribed parameters and missed a scheduled dose of a long-acting opioid due to medication unavailability, with the DON confirming these deficiencies.
Nursing staff did not consistently monitor or document the behaviors and mental health status of three residents with mental disorders or psychosocial adjustment difficulties. One resident on multiple antidepressants lacked physician orders and monitoring for depression symptoms and medication side effects, while two others with behavioral monitoring orders and care plans had no documentation of required monitoring for extended periods. These deficiencies were confirmed by the DON and administrative staff.
Facility staff did not hold Midodrine as ordered for a resident with orthostatic hypotension when systolic blood pressure readings were above the specified threshold. Despite clear physician instructions, the medication was administered multiple times when it should have been withheld, as confirmed by MAR review and DON interview.
Staff failed to properly secure medications by leaving a narcotic on a resident's bedside table and leaving a treatment cart unlocked and unattended in a hallway. The cart contained various prescription medications, some of which were expired, and an opened bottle of Dakins solution without a cap. Facility policy requires locked storage, and both the DON and ADON confirmed these actions were not in compliance.
A resident with a history of dental pain and missing/broken teeth did not receive timely follow-up for recommended dental extractions after a dental consult. Despite ongoing complaints and a care plan noting oral health issues, staff did not arrange the necessary dental appointment, and the facility's dental provider had no referral on file. The deficiency persisted until identified by surveyors.
Facility staff did not update a resident's hospice status in the care plan and MDS after hospice services ended, resulting in continued documentation of hospice care and exclusion from rehabilitation evaluation. The DON confirmed the information should have been updated in all relevant records.
The facility did not document that two residents who refused the pneumonia vaccine were provided education about its risks and benefits. Review of immunization records showed refusals without evidence of education, and the DON confirmed the absence of required documentation.
A resident admitted in 2024 had no documentation of COVID-19 vaccination or evidence that the vaccine was offered, and no historical vaccination data was present in the records. The DON confirmed that the Infection Preventionist is responsible for monitoring vaccination status but acknowledged the absence of information for this resident.
Two residents experienced deficiencies in nutritional care: one had significant unaddressed weight loss without follow-up or documentation, and another did not receive recommended dietary supplements for malnutrition and dysphagia, as staff failed to implement the dietitian's interventions. The DON confirmed these lapses.
Facility staff failed to provide safe and appropriate respiratory care, including not documenting or administering BiPAP therapy as ordered for a resident with chronic respiratory failure, administering oxygen at incorrect flow rates, lacking physician orders with indications for oxygen use, and not changing oxygen tubing as scheduled. Staff interviews confirmed these deficiencies in documentation, adherence to orders, and equipment maintenance.
Significant Medication Error Involving Wrong Antibiotic Administration
Penalty
Summary
Facility staff failed to ensure that a resident was free from significant medication errors when a nurse did not administer medication as prescribed by the physician. Review of a complaint and the resident’s medication administration audit showed that on 12/6/25 at 6 PM, the resident received meropenem, a broad-spectrum carbapenem antibiotic used to treat severe bacterial infections, instead of cefepime, a fourth-generation cephalosporin antibiotic that had been ordered by the physician for a urinary tract infection. This constituted a failure to follow the five rights of medication administration, specifically administering the wrong medication, and resulted in the resident receiving a medication that was not prescribed, although no negative outcome was documented for the resident. The deficiency was identified through observation, record review, and interviews, which confirmed that the medication was not given as ordered and that the resident’s medication administration record reflected the administration of an unprescribed antibiotic for the urinary tract infection.
Failure to Complete Ordered Diagnostic Ultrasound
Penalty
Summary
Facility nursing staff failed to follow a physician’s order to obtain a right upper quadrant ultrasound for a resident whose laboratory tests showed elevated liver enzymes. The resident’s medical record showed that in September 2025 labs revealed elevated liver enzymes, and on 9/18/2025 the physician ordered a right upper quadrant ultrasound. Subsequent review of the medical record revealed no evidence that the ultrasound was completed or that results were obtained. During an interview, the Director of Nursing confirmed that nursing staff did not complete the ordered ultrasound, and the surveyor identified this as a concern related to failure to follow a physician’s order. The deficiency was identified during a complaint survey initiated after a complaint alleging the facility failed to monitor the resident’s status and well-being during the stay. Medical record review on 1/12/26 confirmed the absence of ultrasound results despite the prior order, and the DON’s interview on 1/12/25 further verified that the ordered diagnostic test was not carried out by nursing staff.
Failure to Conduct Annual Performance Reviews and Provide Individualized In-Service Education for GNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for Geriatric Nursing Assistants (GNAs) and did not provide regular, in-service education based on the outcomes of those reviews. This deficiency was identified during a recertification survey, where a review of five randomly selected GNA employee records revealed that none contained documentation of a performance review, despite all being employed for varying lengths of time. The Director of Nursing (DON) confirmed that performance reviews had not been completed for some time and that the process was not current at the time of the survey. Further, the DON acknowledged that in-service education for GNAs could not be tailored to individual needs without the completion of performance reviews. The absence of these reviews and the lack of individualized in-service training was evident for all five GNAs whose records were examined, indicating a systemic issue in the facility's process for monitoring and supporting staff performance.
Failure to Maintain Sanitary and Comfortable Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on two of three nursing units. Observations during the survey revealed multiple environmental concerns, including stained ceiling tiles, missing toilet paper, peeling laminate on bed headboards and footboards, peeling paint on window sills, missing strings for over-bed lights, rusted frames on toilet risers, and separated molding by windows. Several rooms had spackled walls that were not painted, further contributing to the lack of a homelike and well-maintained environment. Additionally, several residents were observed using wheelchairs with torn or cracked vinyl on the armrests, with some exposing the underlying foam padding. Interviews with the Maintenance Director indicated that he had only recently started in his role and was the sole maintenance staff member, occasionally receiving assistance from housekeeping. The facility had recently implemented a new system for reporting repairs, but these environmental deficiencies persisted at the time of the survey.
Failure to Timely Report Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property to the Office of Health Care Quality (OHCQ) within the required timeframes for multiple residents. In several cases, reports of alleged physical abuse, verbal abuse, and theft were not submitted within the mandated 2-hour window for abuse or 24-hour window for misappropriation. Documentation and interviews confirmed that the initial reports were delayed, with some incidents being reported a day or more after the event, and in one case, the facility could not provide evidence of when the report was submitted. Facility leadership, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), acknowledged these delays during interviews, often noting that they were not employed at the facility at the time of the incidents but confirmed the findings based on available records. Specific incidents included allegations of staff physically and verbally abusing residents, missing narcotic medication, and theft of personal items and money. In one instance, a resident alleged being punched and wrestled by a phlebotomist during a blood draw, while another resident reported being hit by a GNA and threatened with a wheelchair. There were also cases where residents' personal property went missing, and the facility did not notify the regulatory agency promptly. In another case, a resident with cognitive impairment and a history of stroke developed unexplained wrist swelling, and the incident was not reported as required, despite the resident's vulnerability. The facility's investigations often lacked timely documentation, and in some cases, there was no evidence of an investigation or report submission at all. Staff interviews and record reviews consistently revealed that the administration was not made aware of incidents promptly, leading to delays in reporting to OHCQ. The failure to report these incidents within the required timeframes was confirmed by facility leadership during the survey process.
Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to provide thorough documentation and investigation of multiple allegations of abuse and misappropriation of property involving several residents. In one instance, a resident alleged physical abuse by a phlebotomist during a blood draw, but the facility's investigation did not include interviews with other residents on the unit who may have had concerns about the phlebotomist. In another case, a resident reported missing money from their purse, but the investigation lacked interviews with all relevant staff from previous shifts and included unsigned staff statements, resulting in an incomplete review. Additional deficiencies were noted in the handling of other incidents. For example, a resident alleged being hit by an LPN, but the facility could not provide any investigation documentation for review. Another resident was observed with a bruise and reported rough handling during ADL care by an agency GNA, but the investigation file was incomplete, lacking staff and resident interviews. In a separate incident, narcotic medication was reported missing, but the facility did not interview all staff who had access to the medication cart during the relevant period, and there was a delay in reporting the discrepancy to nursing administration. Further, the facility did not complete a thorough investigation into a resident's report of missing personal items and money after a hospital stay, as statements from the resident and alleged perpetrator were missing. In another case, a staff member was accused of making a threatening gesture and statement toward a resident, but the investigation did not include statements from named witnesses. In all these cases, the facility's failure to conduct comprehensive investigations and document findings contributed to the identified deficiencies.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required.
Environmental Deficiencies: Mold, Damaged Fixtures, and Unsanitary Conditions
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and visitors. In the Human Resources Director's office, black specks resembling mold were found on the window blinds and air conditioning unit, which also had visible condensation. Staff confirmed the presence of mold and stated it had been reported to administration. In the bathroom near the nurse's station, the base molding was detached, exposing debris and an open area behind the wall, and the toilet paper holder was missing its rod. The sink lacked a gooseneck faucet. The Nursing Home Administrator (NHA) was present during these observations and acknowledged the conditions. Further observations included shower rooms with mold-like substances in the grout, chipped and broken ceramic tiles, and exposed mastic. Soiled washcloths were found on the floor and in a bariatric shower chair, and the ceiling in one shower room had visible cracks. In the activity room, a ceiling tile was completely covered in what appeared to be black mold and was sagging, with staff stating it had been in that condition for a month. The NHA confirmed these findings and noted ongoing issues with the building's gutters, which had not yet been addressed.
Failure to Hold and Document Interdisciplinary Care Plan Meetings After Resident Assessments
Penalty
Summary
Facility staff failed to consistently hold and document care plan meetings that included the interdisciplinary team, residents, and their representatives following comprehensive and quarterly assessments, as required. Medical record reviews for five residents revealed missing or insufficient documentation of care plan meetings after multiple Minimum Data Set (MDS) assessments, including annual and quarterly reviews. In several cases, there was no evidence in the electronic medical record or social work documentation that care plan meetings occurred, and when meetings were held, documentation was sometimes limited to handwritten notes not entered into the official record. Staff interviews confirmed the absence of required documentation and, in some instances, the lack of meetings altogether. For example, one resident's records showed no care plan meeting documentation for several assessment periods, and the social work director acknowledged that notes were not entered into the electronic record. Another resident, who had multiple hospital transfers and readmissions, had only two care plan meeting notes documented despite several MDS assessments. Similar patterns were observed for other residents, with gaps between assessments and documented care plan meetings. The DON and social work staff confirmed that care plan meetings should occur after each quarterly MDS assessment, but acknowledged the lack of evidence to support that this was consistently done.
Failure to Implement Fall Precautions and Smoking Supervision
Penalty
Summary
The facility failed to implement and maintain fall precautions as ordered by the physician for a resident with a history of falls. The resident, admitted with diagnoses including cerebral infarction, cognitive impairment, osteoarthritis, and bipolar disorder, experienced multiple falls from bed. Despite a physician's order and care plan intervention for floor mats to be placed on both sides of the bed, observation revealed that only one mat was on the floor while the other was propped against the wall. Staff interviews confirmed the mat was not in place as required, and the Director of Nursing acknowledged the mat should have been on the floor. The facility did not follow the smoking plan of care for a resident assessed as high risk for unsafe smoking practices. The resident was found to have multiple lighters in their room, contrary to the care plan and facility policy, which required smoking materials to be kept at the nurse’s station and not on the resident’s person. Staff interviews provided conflicting information about the policy, but the Nursing Home Administrator ultimately confirmed that lighters should not be kept by residents and validated the concern that the resident was not following the care plan. Additionally, the facility failed to provide required supervision for residents identified as needing assistance while smoking. Two residents, both assessed as requiring supervision and the use of a smoking apron, were observed smoking unsupervised in the designated area, with one resident not wearing the required apron. Both residents also had smoking materials in their possession, despite care plans stating these should be kept at the nurse’s station. Staff interviews confirmed that supervision was not consistently provided, and the Nursing Home Administrator acknowledged the lack of supervision and the presence of smoking materials with residents who required oversight.
Failure to Provide Timely Medications and Incomplete Narcotic Reconciliation
Penalty
Summary
The facility failed to provide timely pharmaceutical services to meet the needs of residents, as evidenced by multiple instances where residents did not receive their prescribed medications as ordered. For one resident with a physician's order for a daily Nicotine Transdermal Patch, medical record review showed repeated missed doses due to delays in reordering and pharmacy delivery. Nursing notes and the Medication Administration Record (MAR) documented several occasions over multiple months where the patch was not available, and staff interviews confirmed that medications were not always reordered in a timely manner, sometimes due to lapses in communication between staff members responsible for medication administration and reordering. Another resident with a complex medical history, including bacteremia and sepsis, did not receive prescribed IV Vancomycin on several occasions because the medication was not available from the pharmacy or in the facility's automated dispensing system. Documentation in the MAR and nursing notes confirmed missed doses and delays in pharmacy delivery, with blank spaces and notations indicating the medication was not administered. A third resident, admitted with conditions such as hypertension and acute kidney failure, also experienced missed doses of blood pressure medication due to unavailability, as documented in the MAR and confirmed by staff interviews. The facility's own Medication Reordering Policy required nurses to reorder medications when six or fewer doses remained, but staff and leadership acknowledged ongoing issues with timely reordering and medication availability. Additionally, the facility failed to ensure that narcotic medications were consistently reconciled by two nurses at each change of shift, as required for controlled substances. Review of narcotic and controlled substance log binders for all medication carts revealed numerous missing signatures from both oncoming and off-going nurses across multiple shifts and halls. Staff interviews and facility policy confirmed that both nurses were expected to sign off on the narcotic count at each shift change, but this was not consistently done, resulting in incomplete documentation and lack of accountability for controlled medication storage and administration.
Failure to Properly Dispose of Expired Food and Maintain Safe Food Storage Conditions
Penalty
Summary
Facility staff failed to ensure proper disposal of expired and spoiled food items and did not store food in accordance with professional standards for food service safety. During a kitchen tour, multiple yogurt containers with best by dates that had already passed were found in the walk-in cooler. The Dietary Manager acknowledged that these yogurts needed to be discarded. On a subsequent kitchen tour, an open case of tomatoes was found in the walk-in cooler, with several tomatoes displaying white fuzzy material around the stems, indicating spoilage. The Dietary Manager confirmed the tomatoes were bad and removed them for disposal. Additionally, in the nourishment room, there were two vinyl floor tiles placed in front of a leaking ice machine, with a puddle of water and black specks resembling mold on the wall and floor base molding. No caution signs were present to indicate the wet floor. The under-counter cabinets in the nourishment room were observed to be dirty, containing a butcher knife, water spill marks, a red solo cup, a plastic plate cover lid, and a zip lock bag with sweetener packets. The freezer section of the nourishment refrigerator had at least a one-inch ice build-up on all walls. These observations were confirmed with the Nursing Home Administrator during the survey.
Widespread Infection Control Failures and Lapses in Precaution Implementation
Penalty
Summary
Facility staff failed to follow infection control practices and guidelines, resulting in multiple deficiencies related to the prevention and transmission of infection and disease. Observations revealed unsanitary conditions, such as unlabeled and improperly stored basins, urinals, and urine collection hats in resident rooms and bathrooms, as well as soiled gloves and washcloths left in inappropriate places. Mold-like substances were observed in several areas, including shower rooms, the activity room office, and the HR office, with staff confirming awareness of these issues. The facility's own policy required single-resident use and proper storage of bedpans and urinals, which was not followed. During medication administration to a resident with a gastrostomy tube and foley catheter, staff failed to don appropriate PPE and did not post Enhanced Barrier Precautions (EBP) signage as required. Although records indicated an order for EBP and an updated care plan, these precautions were not implemented at the time of observation. Interviews with staff and the DON confirmed that PPE should have been used and signage should have been present for residents with such medical devices. The facility also failed to ensure that residents with infectious diseases or those requiring EBP had appropriate physician orders, care plans, and signage. For example, a resident with a history of sepsis and multiple infections did not have an order or care plan for contact precautions, and staff were unclear about the reason for precautions. Additionally, several residents identified as EBP candidates did not have the required orders or signage on their doors, and staff confirmed these omissions during interviews. These failures were evident across multiple hallways and affected several residents reviewed during the survey.
Failure to Notify Representatives and Physicians of Changes in Resident Condition
Penalty
Summary
Facility staff failed to notify a resident's representative and physician when a BiPAP machine malfunctioned for a resident with chronic respiratory failure and obstructive sleep apnea. The medical record showed that the BiPAP was not administered due to device dysfunction, and while the supplier was contacted and a replacement was arranged, there was no documentation that the resident's representative or physician was informed of the situation or the change in the resident's respiratory support status. Additionally, staff did not notify another resident's representative in a timely manner when the resident, who had dementia, was transferred to the hospital after being found unarousable. The representative was only informed after the hospital had already made contact. Documentation confirmed the delay in notification, and the DON verified that timely notification did not occur in both cases.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse during care provision. On the evening of the incident, two staff members were providing care to a resident who was experiencing significant pain and vocalizing distress, stating that they were dying due to cancer. One staff member responded to the resident by saying, "well go ahead and die then so you can stop all this screaming." This statement was overheard by the resident's family member, who was on the phone with the resident at the time. The family member later visited the facility and received confirmation from the second staff member present that the statement had indeed been made. The resident involved had been admitted with a diagnosis of malignant neoplasm of the bone (bone cancer). The facility's investigation included statements from the family member and the second staff member, both corroborating the incident. The facility's policy defines verbal abuse as the use of disparaging or derogatory terms directed at residents or their families. The administrator confirmed the occurrence of verbal abuse by the staff member during an interview.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific actions or omissions by staff or facility management led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for three residents during the recertification/complaint survey. For one resident with diagnoses including polyneuropathy, chronic pain, osteoarthritis, and gout, the MDS incorrectly indicated that the resident did not receive regular pain medication, despite documentation showing the use of Diclofenac gel four times daily and Gabapentin twice daily. The MDS also failed to code the use of anticonvulsant medication. These errors were confirmed by the MDS Coordinator upon review. Another resident's admission MDS did not capture a documented refusal of medication and weight, even though behavior notes and a care plan addressed non-compliance with the treatment plan. The MDS Coordinator confirmed this omission and stated that the existence of a care plan was mistakenly considered sufficient. Additionally, a third resident's MDS inaccurately reported the number of injections received and failed to document opioid administration, despite medical records showing multiple injections and opioid use. These inaccuracies were verified through staff interviews and medical record reviews.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident, the physician's notes incorrectly documented the administration of Pravastatin 20 mg nightly for secondary stroke prevention, despite the resident not being prescribed this medication since readmission. The Chief Clinical Officer confirmed this was a documentation error and the resident was not supposed to be on Pravastatin. Another resident's Medication Administration Record (MAR) contained multiple blank spaces for several medications, including Seroquel, Metformin, Pregabalin, Senna, Trulicity, Enoxaparin, Normal Saline Solution flush, Humalog insulin sliding scale, and silver sulfadiazine cream. The DON stated that blank spaces on the MAR indicated it could not be determined if the medications were given or signed off. Additionally, a third resident's medical record lacked evidence of care plan meetings in both the miscellaneous section and social work documentation. The Social Work Director reported that notes from a care plan meeting were handwritten in a personal notepad and not entered into the electronic medical record, making them unavailable to other disciplines. These findings demonstrate failures in maintaining legible, accurate, and accessible medical records for residents.
Failure to Ensure Call Bell Accessibility for Residents
Penalty
Summary
Facility staff failed to ensure that residents had access to their call bell controls, as observed during the initial tour. Specifically, one resident was found with the call bell cord and plunger on the floor near the headboard and out of reach, and the resident was unaware of its location. Another resident's call bell was also observed on the floor and out of reach. During an interview, a Geriatric Nursing Assistant/Certified Medication Tech confirmed that the call light should be within reach and acknowledged that it was not accessible to the resident at that time. These findings were identified for two residents out of a sample of sixty-four during the survey, and the facility was informed of these observations at the exit conference.
Failure to Honor Resident Rights to Organize and Participate in Groups
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified when it was observed that residents were not provided the opportunity or support to form or participate in such groups within the facility. The report notes that the facility did not facilitate or respect the organization and participation of these groups as required.
Failure to Complete Baseline Care Plan and Provide Medication Summary Upon Admission
Penalty
Summary
The facility failed to complete a baseline care plan (BLCP) within 48 hours of admission for one resident, as required. Review of the medical record for this resident showed no evidence that a BLCP was created or documented. The BLCP is intended to include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. Additionally, there was no documentation that a summary of the BLCP or a current medication list was provided to the resident or their representative. Interviews with the Director of Nursing (DON) revealed uncertainty regarding the required timeframe for BLCP completion, with the DON incorrectly stating it was within 72 hours instead of 48. The DON also indicated that the admitting nurse initiates the BLCP and that each discipline contributes, but was unable to locate the BLCP in the resident's record or provide evidence that a copy was given to the resident or representative. Ultimately, the DON confirmed that a BLCP was never completed for the resident in question.
Failure to Develop Timely Care Plan for Catheter Use
Penalty
Summary
Facility staff failed to develop a care plan to address a resident's use of an indwelling urinary catheter, despite a physician's order for catheterization and documentation in the Minimum Data Set (MDS) assessments indicating the presence of a catheter. The Care Area Assessment (CAA) from the resident's Admission MDS noted that the Interdisciplinary Team (IDT) agreed to create a care plan for the catheter, but a review of the clinical record revealed that no such care plan was in place for approximately three months following admission. During the survey, the Director of Nursing (DON) was interviewed and initially did not provide evidence of a care plan addressing catheter use. When a care plan was later produced, it was found to have been initiated only after a significant delay, well after the resident's admission and the original physician's order. The DON acknowledged that the resident went without a required care plan for catheter use during this period.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not properly assessing pain, not following physician orders for pain medication parameters, and not documenting or providing non-pharmacological interventions prior to administering PRN pain medications. For one resident, pain assessments were only documented on the day shift, despite orders to assess pain every shift, and pain scores were not consistently recorded. Additionally, the order for oxycodone lacked specific pain parameters after a certain date, and non-pharmacological interventions were not documented as attempted before administering PRN pain medications for several months. For another resident, the MAR showed that PRN oxycodone was administered multiple times without documentation of non-pharmacological interventions being attempted first, as required by the care plan and physician orders. The resident's orders included both Tylenol and oxycodone for different pain levels, but staff administered oxycodone for pain scores that should have been managed with Tylenol, and there was no documentation of Tylenol being given for those pain levels. The DON confirmed that non-pharmacological interventions should be offered and documented prior to PRN pain medication administration and that pain medication parameters should be specified in the orders. Additionally, a scheduled dose of Oxycontin was not administered to a resident because the medication was not available, and the pharmacy had to be contacted for delivery. Staff interviews revealed that medication reordering was based on nursing judgment, and delays could occur due to the need for physician-signed forms for narcotic medications. The DON acknowledged awareness of the missed dose and the issues with pain medication administration and documentation.
Failure to Monitor and Document Behavioral Health Interventions
Penalty
Summary
Nursing staff failed to adequately monitor and document the behaviors and mental health status of three residents with mental disorders or psychosocial adjustment difficulties. One resident, who was prescribed multiple antidepressant medications for depression, did not have a physician order for monitoring signs and symptoms of depression or medication side effects, despite a care plan intervention requiring such monitoring. The lack of monitoring was confirmed by the Director of Nursing, who acknowledged that appropriate orders and monitoring were not in place prior to the surveyor's inquiry. Two additional residents with orders and care plans for behavioral monitoring related to psychiatric or behavioral issues did not have documentation of behavior monitoring as required. For one resident, there was an order to monitor target behaviors every shift, but no documentation was found for several months until after the surveyor raised the issue. Another resident had a physician order and care plan for monitoring specific behaviors associated with schizophrenia, but the required monitoring was not documented on the Medication Administration Record. These failures were confirmed by facility administrative staff during the survey.
Failure to Hold Medication per Physician Order
Penalty
Summary
Facility staff failed to follow physician orders regarding the administration of Midodrine for a resident with orthostatic hypotension. The resident had a specific order to hold the medication if the systolic blood pressure was above 130. Clinical record review showed multiple instances in June and July where the resident's systolic blood pressure exceeded 130, yet the medication was still administered. This was confirmed through review of the Medication Administration Records and an interview with the Director of Nursing, who, along with the surveyor, identified the occurrences where the medication was given contrary to the physician's order.
Improper Storage and Security of Medications and Biologicals
Penalty
Summary
Facility staff failed to properly store and secure medications and biologicals as required. In one instance, a narcotic medication, Methadone 115mg, was left on a resident's bedside table after a staff member administered care, rather than ensuring the medication was taken or following an order to leave it at bedside. The staff member acknowledged that leaving the medication unattended was not appropriate. The Director of Nursing confirmed that medications should not be left at the bedside unless specifically ordered. Additionally, a treatment cart was observed unlocked and unattended in a hallway, allowing access to various prescription creams, ointments, and other medications. The cart contained expired items, including iodoform packing strips and Nystatin Zinc tubs, as well as an opened bottle of Dakins solution without a cap. An agency nurse present at the time stated she had not checked the cart that morning. Facility policy requires that only authorized personnel have access to locked compartments, and both the Director of Nursing and Assistant Director of Nursing confirmed the cart should have been locked.
Failure to Arrange Timely Dental Services After Consultant Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to arrange for timely dental services for a resident following a dental consultant's recommendation. The resident, who had a history of oral/dental health problems including missing and broken teeth, complained of tooth pain to both staff and family. The care plan documented ongoing oral health issues and required staff to monitor and report symptoms such as pain, missing or broken teeth, and other oral abnormalities. Despite a dental consult identifying the need for extractions of fractured and retained root tips, there was no evidence that the facility made arrangements for the recommended dental treatment. Interviews with the resident, the resident's son, and facility staff revealed that the resident continued to experience dental pain and had not received follow-up care after the dental consult. The DON and unit manager confirmed that no appointment had been set for the necessary dental extractions, and the facility's dental service provider had not received a referral for the resident. The lack of follow-up persisted until the surveyor's intervention, indicating a failure to provide or obtain necessary dental services within a reasonable timeframe as required.
Failure to Update Resident Hospice Status in Records
Penalty
Summary
Facility staff failed to ensure timely updates to a resident's hospice status, as evidenced by discrepancies in the medical record, care plan, and Minimum Data Set (MDS). Documentation from a contracted company indicated that hospice care for the resident began on 03/29/25 and ended on 05/29/25. However, the resident's care plan still listed hospice care as active, and the MDS completed after the hospice discharge also indicated ongoing hospice care. Additionally, the resident was not evaluated for rehabilitation services because staff believed the resident was still under hospice care. The Director of Nursing confirmed that the hospice discharge information should have been updated in all relevant records and lists, but this was not done.
Lack of Documentation for Pneumonia Vaccine Education
Penalty
Summary
The facility failed to provide education regarding the risks and benefits of the pneumonia vaccine to two residents who refused the immunization. During a review of five residents' immunization records, it was found that both residents had documented refusals for the pneumonia vaccine, but there was no evidence in the medical records indicating when the vaccine was offered or that any education about the vaccine's risks and benefits was provided. In an interview, the DON confirmed that education should be given and documented for refusals, but acknowledged that such documentation was not present for these residents.
Failure to Monitor and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to properly monitor and document the COVID-19 vaccination status for one resident out of five whose immunization records were reviewed during a recertification and complaint survey. Specifically, a resident admitted in July 2024 had no evidence in their records of receiving the COVID-19 vaccine, nor was there documentation that the vaccine had been offered or that historical vaccination data had been obtained. During an interview, the DON confirmed that the Infection Preventionist is responsible for monitoring vaccination status upon admission, but acknowledged that there was no information available for this resident's COVID-19 vaccination status.
Failure to Address Weight Loss and Implement Dietitian Recommendations
Penalty
Summary
The facility failed to address significant weight loss and did not follow dietitian recommendations for two residents reviewed for nutrition. For one resident, a notable weight loss of 12.2 lbs (7.17%) was documented over a period of just over a month, but there was no evidence of a follow-up nutrition evaluation or documentation regarding this change. Interviews with staff confirmed that the expected protocol—re-weighing, notifying the dietitian and provider, and documenting the change—was not followed, and the Director of Nursing validated that no documentation or intervention occurred after the weight loss was identified. For another resident with diagnoses of malnutrition and dysphagia, the dietitian recommended offering pudding and shakes twice daily to increase caloric intake. However, these recommendations were not implemented, as there were no physician orders for the suggested supplements after the assessment. The resident was admitted to hospice care and subsequently died in the facility. The Director of Nursing confirmed that staff did not follow the dietitian's recommendations for this resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
Facility staff failed to provide appropriate respiratory care to meet the needs of several residents, as evidenced by multiple deficiencies in documentation, administration, and maintenance of respiratory equipment. For one resident with chronic respiratory failure and obstructive sleep apnea, there were repeated failures to document the administration of BiPAP therapy across several months, including specific dates in November 2022, January 2023, November 2024, and June 2025. Additionally, there was an instance where the BiPAP was not administered due to equipment malfunction, and the absence of documentation made it unclear whether the therapy was provided as ordered. Other deficiencies included the administration of oxygen at incorrect flow rates and the lack of physician orders specifying the indication for oxygen therapy. One resident was observed receiving oxygen at a higher flow rate than prescribed, and the physician order did not include the required indication for use. Another resident's oxygen tubing was not changed according to the prescribed schedule, with tubing dated beyond the weekly change requirement, and the oxygen was administered at a higher rate than ordered. Staff interviews confirmed these findings, including the lack of proper documentation, failure to follow physician orders, and improper maintenance of respiratory equipment.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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