Autumn Lake Healthcare At Ruxton
Inspection history, citations, penalties and survey trends for this long-term care facility in Towson, Maryland.
- Location
- 7001 Charles Street, Towson, Maryland 21204
- CMS Provider Number
- 215077
- Inspections on file
- 24
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 39
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Ruxton during CMS and state inspections, most recent first.
Food Held at Improper Temperatures: A resident reported receiving sour, spoiled milk at breakfast. Surveyors later found milk at 47.3F on a test tray and 42F from the walk-in refrigerator, while the CDM stated milk should be held between 39F and 41F. Surveyors also observed an open refrigerated well holding milk and other refrigerated items with no thermometer or temp log present, and noted the reach-in refrigerator was out of service.
Unsanitary Kitchen, Food Storage, and Dining Area Conditions: Surveyors observed unclean food prep surfaces, debris on cutting board holders, soiled floors, rodent pellets, and dirty food containers in the kitchen. The FSD acknowledged a recent mouse problem and ongoing pest concerns. Surveyors also found an out-of-service reach-in refrigerator being used for food storage, dirty fan covers and piping in the walk-in refrigerator, rust and debris on the steam table, and soiled, damaged dining chairs and surfaces in a resident lounge area.
The facility failed to keep the garbage area sanitary. The surveyor observed an uncovered rolling trash container with food debris and loose trash scattered around it, along with broken furniture, mattresses, pallets, broken equipment, wet cardboard, and trash stacked against vents to the electrical room. The FSD acknowledged the concerns and reported raccoons were sometimes present, while the DON and Administrator were notified. The DM later confirmed an ongoing mouse issue and stated staff were not breaking down trash or boxes, causing trash cans to overflow.
Multiple infection control lapses were observed, including residents accessing an ice cooler without hand hygiene and leaving the scoop in the ice, laundry and trash placed on the floor in resident hallways near PPE and precaution rooms, soiled bedding and contaminated items in care areas, and staff failing to disinfect shared equipment such as a portable vital signs monitor, glucometer, and wrist cuff between resident uses. Staff were also observed moving between residents without proper hand hygiene and handling PPE and linens inconsistently.
Kitchen Equipment Not Maintained in Safe Operating Condition: The surveyor observed multiple pieces of essential kitchen equipment out of service, including a reach-in refrigerator reading 78F and being used for staff food and tray line items, one of two steamer compartments broken, one of six steam table wells not working with tape over the control and a stated electrocution hazard, and one convection oven compartment unable to hold temperature. FSD #12 said the broken equipment had been in the maintenance system for about 3 months, companies were not coming to fix items until bills were paid, and the kitchen was boiling food for over 200 residents. The kitchen door handle was also missing, leaving sharp metal edges.
Emergency water supply was not properly maintained onsite. The FSM told the surveyor the water was not in the building, and the Administrator stated they did not think emergency water was needed onsite. When the supply was finally shown, the surveyor observed crushed cases, opened and uncapped jugs, empty jugs, white powder on some cases, and water with outdated best-by dates. The amount on hand was only about 250 to 300 gallons and was confirmed by the Administrator and FSM to be insufficient for 3 days for the resident census.
Pest control was not effectively managed in the facility. Surveyors observed mouse droppings on a food prep table in the kitchen, unclean food containers, overfilled and poorly maintained trash areas, and rod-shaped pellets on the activity room floor. The FSD reported an ongoing mouse problem, the DMT confirmed continued pest issues, and residents reported seeing mice. Pest control records showed repeated active concerns, poor sanitation, voids, and confirmed pest activity in the kitchen and near the ice machine.
A resident reported not consistently receiving scheduled showers and not having their preference for daytime showers honored. Staff indicated the resident was scheduled for showers on the 3–11 shift, while the resident preferred showers on the 7–3 shift so they would occur before wound dressing changes. Documentation showed multiple missed scheduled showers over several months and one shower documented that the resident denied receiving. The resident’s family member confirmed the resident had complained to nursing staff and was told showers had to occur at night despite the resident’s stated preference.
A resident’s representative submitted multiple written and oral grievances alleging unaddressed care concerns, including ignored requests for water and repositioning, inadequate pain management, lack of follow-up for infections, barriers to participation in activities, denial of access to staff assignment information, unaddressed ear pain and spasms, unavailability of needed equipment, pest issues, and absence of a complete care plan. Facility grievance forms indicated that a representative would review and contact the complainant within 72 hours and document findings, resolution, referral, and dates received and shared. For these grievances, only findings and resolutions were completed, and forms were signed and dated by a Grievance Officer and an NHA on a date preceding the NHA’s hire, while referral information, date received, and date shared with the complainant were left blank. The representative reported never receiving acknowledgment, investigation updates, or written decisions, and the DON could not explain the documentation discrepancies or provide evidence that the required written decision was issued.
A resident with a left leg wound did not have their dressing changed according to a daily day-shift physician order, as surveyors observed the same dated dressing remaining in place over multiple shifts despite staff documenting diabetic foot and ankle checks that should have revealed the unchanged dressing. In a separate case, another resident’s medications, including oxybutynin, midodrine, tizanidine, and Eliquis, were documented on the MAR as administered several hours after scheduled times without any notation of clinical justification, resident refusal, physician orders to hold, or physician notification, and staff could not explain the delays during interviews.
A resident with an order for PRN Oxycodone for pain rated 5–10 on a 1–10 scale did not receive pain medication before a wound dressing change, despite having requested it in advance. During the observed procedure, the resident reported being in constant pain and confirmed they had asked for pain medication earlier but had not received it. The nurse performing the dressing change stated she was occupied with another resident’s dressing change and therefore did not administer the pain medication before starting this resident’s wound care. Record review confirmed the PRN Oxycodone order, and the DON later acknowledged that the medication should have been given prior to the wound care.
A resident received PRN Oxycodone 15 mg on multiple occasions when their documented pain score was 4, even though the physician’s order specified administration only for pain rated 5–10 on a 1–10 scale. MAR review showed repeated instances where the opioid was given despite the pain level being below the ordered threshold. When interviewed, the DON acknowledged that the medication should not have been administered under those conditions.
Facility staff failed to ensure two residents received required routine and follow-up dental care. One resident, observed to have few or no teeth, had no documented dental consult for over a year and had not been seen by a dentist since the prior year, despite requirements for at least annual oral assessments. Another resident with missing teeth and cavities had sporadic dental encounters, including attempted visits where the resident was unavailable or in isolation, and a recommended dental hygiene visit that was never rescheduled. A nursing note documented that a molar tooth came out while the resident was talking, and the resident was ordered to be seen by dental services, with the next documented dental visit occurring only after this event.
Unassessed Self-Administration of Medication: A resident kept a labeled bottle of magnesium citrate in the room for PRN use, and an LPN stated the medication was left with the resident to use when constipated. The MD was unaware the resident had the medication in the room, and record review found no order or documentation of an assessment for safe self-administration.
A resident stated they did not receive quarterly statements for their personal funds account. When surveyors requested signed copies showing the resident received the statements, the facility did not provide them at exit, and the copies later emailed were unsigned. This was identified for 1 of 2 residents reviewed for a personal funds account.
Poor Room Cleanliness and Maintenance: Multiple resident rooms had broken or worn furniture, damaged walls, scraped flooring, and visible soilage. A resident reported a walker was scraping the floor and the concern had not been resolved, while another resident room had crumbs, trash, a urine odor, and a wet bed that had not been changed when the resident wanted to lie down. A Unit Mgr confirmed additional wall damage in another room.
A resident reported that the Administrator took a $19,780 Social Security disability back-pay check made out only to the resident and said it was used to pay facility care, while about $2,000 was placed in an RFMS account without statements being provided. Facility leadership said the money was owed to the facility because the resident had been on Medicaid and disability had not been approved right away, but requested billing, RFMS, check, and Medicaid-notification records were not produced by exit.
Failure to Provide Written Transfer/Discharge and Bed-Hold Notifications: The DON and record reviews showed that written transfer/discharge notices, bed-hold information, and Ombudsman notifications were not properly documented for multiple residents. In some cases, forms were incomplete or unsigned, and in others the facility could not verify that the resident, RP, or Ombudsman received the required written notice. One resident with cognitive impairment had incomplete transfer and bed-hold forms, while another cognitively intact resident stated no form was offered or received.
Late MDS Assessments: The facility failed to complete and submit MDS assessments on time for two residents. An MDSC-RN acknowledged that one resident’s annual assessment was signed and submitted late, and that another resident’s assessment was completed, locked, and submitted after the required timeframe. The records showed delayed signatures and late submission/locking compared with the required MDS deadlines.
An RN prepared Vitamin B-1 100 mg for a resident from a bottle labeled with another resident's name, stating it was house stock and matched the ordered medication, route, and dose. The ADON/IP later confirmed that medications labeled for a specific resident cannot be used as house stock for others because they were dispensed for that resident.
A resident with a tracheostomy, epilepsy, and a gastrostomy tube was left unattended during a strong coughing episode while an LPN was administering meds via G-tube and checking for nebulizer meds. The resident was then heard falling and was found on the floor mat with a laceration and bruising near the eye. The DON confirmed the resident should not have been left alone during that time and that the care plan identified the resident as being at risk for falls related to poor safety awareness and strong cough reflexes.
Incomplete and inaccurate resident records were found for three residents. One resident received PRN morphine for ongoing pain, but the MAR did not document pain scores before each dose. Another resident’s clothing purchases were reflected in account records and receipts, but the personal inventory sheet was not updated to show the items received. A third resident had two completed MOLST forms in the chart, and the older form had not been voided.
Housekeeping and maintenance services were not maintained to keep resident areas sanitary, orderly, and comfortable. Surveyors observed dirty clothing, urine odors, stains, clutter, damaged furniture, a broken shower room lock, a cracked toilet, wet flooring, scattered trash, stained ceiling tiles, and a cracked glass door in common areas. Staff observed and acknowledged the concerns during the survey.
A resident received multiple morning medications, including those for bowel regimen, edema, anxiety, bipolar disorder, cellulitis, and diabetes, several hours after their scheduled administration times. The DON confirmed that medications were documented as late and stated that staff are expected to administer and document medications on time, indicating a failure to meet professional standards of practice.
The facility failed to maintain an effective pest control program, leading to a mice infestation on the third floor affecting several residents. Observations showed no mice traps in rooms, and interviews revealed that residents experienced fear and sleepless nights due to the presence of mice. Despite pest control visits, no traps were placed in the facility except in ceilings, and staff were unaware of effective measures to address the issue.
The facility failed to maintain clean respiratory equipment for four residents, leading to potential exposure to contamination and improper airflow. Observations revealed dusty oxygen concentrators and filters, with staff unaware of cleaning schedules. Additionally, a resident's oxygen mask and tracheostomy collar were improperly stored, contrary to facility policy.
The facility failed to supervise medication administration for three residents, leading to unsupervised medications being left in rooms. A resident with severe cognitive impairment was left with a medication cup, another with intact cognition had pills left unattended, and a third with moderate cognitive impairment had unauthorized medications in their room. These actions were against the facility's policy requiring observation during medication administration.
A resident's family member filed a grievance alleging verbal threats by a CNA, but the facility failed to document and investigate the complaint thoroughly. The cognitively intact resident reported feeling threatened, yet the grievance lacked specific details, and the investigation did not include interviews with other residents. The facility's policy requires thorough documentation and investigation, which was not followed, leading to dissatisfaction with the resolution.
A facility failed to provide an ongoing program of meaningful activities for a resident with severe cognitive impairment, dementia, anxiety, and insomnia. The resident's interests in music and religious activities were not adequately addressed in the care plan, and observations showed the resident was often left alone without engaging activities. The Activity Director confirmed a lack of documentation and awareness of the need to document activities, leading to a deficiency in meeting the resident's needs.
A resident with a history of stroke and hemiplegia was not provided with a recommended carrot orthosis for a hand contracture, as documented in their occupational therapy discharge summary. The resident's care plan and physician's orders did not reflect the need for the orthosis, and staff interviews revealed a lack of awareness and documentation regarding its use. This oversight had the potential to lead to increased contracture, pain, or skin breakdown.
The facility failed to ensure proper PPE use for two residents on precautions. A resident with recurring c-diff had staff entering their room without gowns or gloves, despite posted contact precautions. Another resident with a gastrostomy tube and other conditions had an LPN administering medications without a gown, contrary to enhanced barrier precautions. Staff interviews revealed misunderstandings about PPE requirements, despite clear facility policies.
A resident with schizophrenia, bipolar disorder, and type 2 diabetes refused insulin, leading to a 911 call. The LPN used strategies like offering pudding to encourage medication compliance, but these interventions were not documented in the care plan. The surveyor noted this deficiency during a review with the DON.
A resident with multiple health conditions experienced five falls over four months due to inadequate supervision and failure to follow care plan interventions. Despite being at high risk for falls, the resident was left unattended, resulting in prolonged periods on the floor. Staff interviews revealed that required monitoring was not conducted, contributing to the incidents.
The facility's ineffective pest control program resulted in a mice infestation, with reports and observations of mice in various rooms, including patient areas. Residents and families expressed concerns, and the Nursing Home Administrator acknowledged the issue but indicated it would take time to resolve. An open exit door on the ground floor further exacerbated the problem by allowing easy access for rodents.
The facility failed to report abuse allegations and an injury of unknown origin within required timeframes to the OHCQ. Incidents involving three residents were not reported timely, and investigations were missing. The DON and NHA could not locate necessary documentation, acknowledging the deficiency.
The facility failed to investigate multiple alleged incidents of abuse, neglect, and misappropriation involving several residents. In one case, a resident reported being smacked by a staff member, but no investigation was found. Another resident reported theft and assault, but the facility could not provide documentation. An alleged employee-to-resident abuse incident also lacked investigation, and a misappropriation case was missing critical details. The Administrator mentioned a possible intervention, but it was undocumented.
A resident with multiple diagnoses, including obstructive uropathy and dementia, developed a scrotal ulcer. The ulcer was noted, but treatment was delayed for three days, and there was no documentation of the ulcer's size or description. The DON confirmed the delay and lack of documentation, although the ulcer healed within 15 days.
A facility failed to ensure a physician wrote, dated, and signed progress notes at each visit, as required by policy. A resident's medical records showed significant delays in signing notes, with some signed nearly a month after the visit. The NHA acknowledged the issue, noting the physician had moved out of state.
A resident with chronic pain and anxiety experienced repeated unavailability of prescribed medications, leading to calls to 911. The facility struggled with timely medication orders, particularly over weekends, as acknowledged by the LPN and DON. Despite a QAPI plan initiated in early 2024, the issue persisted, with the resident still facing medication shortages in September 2024.
The facility failed to maintain accurate and timely medical records for two residents. One resident's record was updated posthumously with an activity assessment, while another resident's records contained incorrect vital sign dates, not matching the actual exam dates. These discrepancies were confirmed by the DON and NHA.
Food Held at Improper Temperatures
Penalty
Summary
The facility failed to ensure food was maintained at an appropriate temperature in accordance with professional standards for food service safety. During an interview, Resident #17 reported that at breakfast their milk was cold but sour and spoiled. During palatability testing, the facility’s CDM provided a test tray and the milk temperature was observed at 47.3F. The surveyor then observed the facility’s milk supply in the kitchen and had the CDM pull a milk carton from the walk-in refrigerator, where it was immediately tested at 42F. The surveyor interviewed the CDM, who stated that the expected temperature for milk is between 39F and 41F. The surveyor also observed an open refrigerated well adjacent to the steam table where milk and other refrigerated food items were being held. When asked about temperature monitoring for the well, the CDM confirmed there was no thermometer present, and no temperature log was observed for the well. After surveyor intervention, the RFSD was observed directing the CDM to obtain and place a thermometer into the well. The surveyor also noted that the facility’s reach-in refrigerator was not working and was out of service.
Unsanitary Kitchen, Food Storage, and Dining Area Conditions
Penalty
Summary
The facility failed to ensure professional standards for food service safety were followed and failed to maintain a sanitary kitchen environment during the recertification survey. On the initial kitchen tour, the surveyor observed an unclean food prep table with a brown and white substance present, a metal cutting board holder rack with white and brown crusty debris, and soiling and food crumbs on the flooring below the two-compartment sink. The surveyor also observed a two-tier food preparation table with prepped pork on the top tier and, on the lower tier, numerous dark rod-shaped pellets, food debris, and yellow sticky liquid matter near containers of corn starch, flour, sugar, white rice, and thickener powder. During an interview and dual observation, the Food Services Director stated the building had a mouse problem in the last six months, that the health department had been out several times investigating mice, and that the facility had changed exterminators but still had some mice. The surveyor observed the exterior surfaces of the food containers to be unclean with staining, food crumbs, and cloudy areas, and observed debris on the mounted scoopers inside the sugar and flour containers. The surveyor also observed a movable flooring surface leading to the walk-in refrigerator, a reach-in refrigerator marked out of service with an interior temperature of 78F, and learned from the Food Services Director that the unit was also being used to hold food items needed for tray line and that the facility lacked a designated staff beverage area. The surveyor further observed unsanitary and damaged conditions in resident dining and food service areas. In the second floor lounge, the wall near the resident food refrigerator had white spackling with white powder on the floor beneath it, and six of seven dining chairs had dark soiling on the arm rests. In the walk-in refrigerator, the surveyor observed dirty fan covers, dark gritty debris on the ceiling and piping, and a steady drip of clear liquid. At the tray line, the exterior equipment panel had fuzzy gray matter, the steam table had rust-colored areas and black taping holding food crumbs between the metal surface and prep surface, and a nearby table used for food service had rough worn edges with exposed particle board. The surveyor also noted the steam table and table condition during the exit process, and the damaged table was later observed marked do not use.
Unsanitary garbage area with overflowing trash and pest concerns
Penalty
Summary
The facility failed to ensure the garbage area was maintained in sanitary condition. During the initial tour, the surveyor observed one uncovered rolling trash container parked in the dumpster area adjacent to an entrance to the kitchen, with copious food trash and food debris no longer contained within trash bags, including food cups, open food containers, food matter, open milk containers, rice, carrots, soda bottles, juice containers, and protein shake cartons. Trash items and pieces of food were also scattered on the ground near the container, along with two broken overbed tables, two sitting chairs, numerous wooden pallets, numerous trash cans with broken equipment, bed mattresses, several trash cans on their side, a broken mop bucket, and various pieces of wet cardboard. The surveyor also observed various pieces of plastic and paper trash and bags of ice melt stacked against vents leading into the facility's electrical room. During the observation, the Food Service Director acknowledged the concerns and stated that raccoons were sometimes present in the garbage area. The surveyor additionally noted signs indicative of a pest issue in the kitchen during the initial tour. Later interviews confirmed the facility continued to have a pest issue with mice, and the Director of Maintenance stated that staff were not breaking down trash or boxes as they were supposed to, which was causing trash cans to not have enough space. A receipt for a 20-yard container to remove the garbage was later provided to the surveyor.
Infection Control Lapses With Shared Equipment, Hand Hygiene, and Resident Care Areas
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program as evidenced by multiple observations of poor infection control practices throughout the survey. Residents were observed accessing the floor two nutrition room ice cooler without hand hygiene, including one resident who used a rolling walker, removed a hand from the walker handle, opened the nutrition room door, and scooped ice into a bath basin while touching the inside surface of the ice cooler with an arm. The resident left the ice scoop and handle directly in the ice, and trash was observed on the floor around the cooler. A second resident was observed doing the same, obtaining ice from the cooler without hand sanitization and leaving the scoop and handle in the ice. The surveyor also observed laundry and trash handling concerns in resident care areas. A mesh bag of laundry was found on the floor in the hallway outside a resident room with contact precautions signage, positioned against a PPE cart and beneath a floor caution sign. On another date, bagged laundry was again observed on the floor outside two resident rooms. In addition, brown matter was observed on the mattress of a resident’s bed during a dual observation with an LPN. A clean linen cart was also observed with a severely worn cover, a hair comb with strands of hair on top, and two residents’ personal body wash bottles stored with linens and incontinence care products. Another observation showed a GNA wearing PPE in the hallway while obtaining linens from a cart and picking up two bags of trash from the floor, then later exiting a room with contact and droplet precautions signage while still wearing PPE and moving linen out of the room. Shared resident equipment and hand hygiene practices were also observed to be deficient. An RN used the same portable vital signs monitor, blood pressure cuff, and pulse oximeter for three residents without disinfecting the equipment between uses. An LPN used a portable glucometer for one resident, discarded gloves, exited the room, and returned the glucometer to the medication cart without disinfecting it; the same LPN also used a black portable wrist cuff for another resident and did not disinfect it afterward. The LPN additionally administered insulin to one resident, removed gloves, and then proceeded to obtain a blood sugar reading for another resident without washing or sanitizing hands in between resident care.
Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
Essential kitchen equipment was not maintained in safe operating condition. During the initial kitchen tour, the surveyor observed a single-door reach-in refrigerator with exterior signage stating it was out of service, while the interior thermometer read 78F. FSD #12 stated there was no designated staff beverage area and that the refrigerator was being used to hold staff food items and food needed for the tray line. FSD #12 also stated the current Administrator knew bills were still being sent to the previous Administrator and that companies were not coming to fix equipment until the bills were paid. The surveyor also observed one of two electric convection steamer compartments was operational, one of six steam table wells was operational, and one of two convection oven compartments was unable to hold appropriate temperature. FSD #12 stated one steamer compartment was broken and the kitchen was boiling food for over two hundred residents, and expressed concern about burn hazards from boiling large quantities of food. The surveyor observed tape over the knob below one steam well, and FSD #12 confirmed the steam well was not working and stated it could electrocute someone if turned on. FSD #12 further confirmed the broken kitchen equipment had been entered into the maintenance system for approximately three months and that staff had repeatedly been informed the equipment needed to be working. The surveyor also observed the kitchen door handle was missing, leaving an open hole with sharp metal edges, and FSD #12 stated it broke the day before.
Emergency Water Supply Not Maintained Onsite
Penalty
Summary
The facility failed to ensure an onsite emergency water supply was available and maintained in usable condition. During the recertification survey, the surveyor reviewed census documentation showing 168 residents and asked the Food Service Manager where emergency water was stored. The FSM stated the water was not in the building and confirmed it was not stored anywhere onsite. When the Administrator was later asked to show the emergency water supply, the surveyor observed the Administrator ask the FSM for keys to the emergency water supply room, and the FSM retrieved a key. The Administrator stated they did not think emergency water was needed onsite. When the emergency water supply was observed with the Administrator and FSM, the surveyor found cardboard cases of gallon jugs that appeared crushed inward, opened and uncapped jugs, several empty capped jugs, cases with a layer of white powder present, and some water with best-by dates from 2024 and 2025. The supply was estimated at about 250 to 300 gallons, and both the Administrator and FSM confirmed it was not enough for the facility’s residents for three days. The FSM stated the water was not in condition to serve to residents and explained that temperature changes in the storage room had caused gallons of water to explode, with maintenance work recently done in the room. The facility policy stated the Dietary Manager maintains a three-day supply of bottled water at no less than 3 gallons per resident per day, and the disaster and emergency response plan stated the facility has an emergency supply of water located in storage on the lower level.
Pest Control Program Not Effectively Managed
Penalty
Summary
The facility failed to ensure effective management of pest control. During the initial tour of the kitchen, numerous dark rod-shaped pellets approximately the size of a grain of rice were observed scattered on the lower tier of a two-tier food preparation table located across from the two-compartment sink, along with food debris and yellow sticky liquid matter near containers of corn starch, flour, sugar, white rice, and thickener powder. The exterior surfaces of the food containers on the lower tier were also observed to be unclean, with staining, food crumbs, and cloudy appearing areas. During interview and observation, the Food Service Director stated the building had a mouse problem in the last six months, that the health department had been out several times investigating mice, that the facility had changed exterminators, and that there were still some mice. The Food Service Director also stated extra cleaning had been done, but not since the snow storm. In the exterior trash area adjacent to the kitchen entrance, an uncovered rolling trash container was observed with copious food trash and debris no longer contained within bags, along with scattered food items on the ground, broken overbed tables, chairs, wooden pallets, broken equipment, mattresses, trash cans on their side, a broken mop bucket, wet cardboard, and plastic and paper trash stacked against vents leading into the electrical room. The Food Service Director acknowledged that raccoons were sometimes present in the garbage area. Residents and a family member reported seeing mice in the facility, and the Director of Maintenance confirmed the facility continued to have a pest issue with mice. He stated staff were not breaking down trash or boxes as required, causing trash cans to not have enough space, and reported the pest control problem had not been handled correctly at first. Survey review also showed repeated pest control concerns documented over many months, including active concerns, poor sanitation, large voids, mice activity near the loading dock and kitchen, reports of mice in the kitchen, and confirmed pest activity behind the ice machine. The surveyor also observed overfilled dumpsters and dark rod-shaped pellets scattered on the floor of the activity room.
Failure to Honor Resident’s Shower Preferences and Schedule
Penalty
Summary
Facility staff failed to honor a resident’s stated preference and schedule for showers, resulting in missed showers and showers being scheduled at undesired times. During a wound dressing change observation, the resident reported that they were supposed to receive two showers twice a week in the evening but did not always receive them. The staff member performing the dressing change stated the resident was scheduled for showers on the 3–11 shift, while the resident stated a preference for showers on the 7–3 shift so that showers would occur before wound dressings were changed, not after. The resident explained that even if the old dressing became wet, it would have to be removed anyway, so getting it wet would not matter. Review of the facility’s Documentation Survey Report showed multiple dates on which the resident did not receive scheduled showers, including several dates over a three‑month period. The record also showed a shower documented on one date that the resident denied receiving. The resident’s sister reported that the resident had complained to nursing staff about not being showered and that staff told the resident showers had to be taken at night, despite the resident’s expressed preference for daytime showers.
Failure to Follow Grievance Process and Communicate Outcomes to Resident Representative
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance process and to honor a resident’s and resident representative’s right to voice grievances without discrimination or reprisal. A resident representative submitted multiple Complaint/Grievance Forms in January and February 2025 regarding the resident’s care, treatment, staff behavior, and quality of life. These grievances included concerns about staff not responding to requests for water during a period when the resident was on large amounts of antibiotics and had limited upper body mobility, staff failing to turn and reposition the resident during the night shift despite requests, and repeated unfulfilled requests to place the resident in a chair so the resident could participate in activities. Additional grievances documented by the representative included allegations of inadequate pain management, lack of follow-up or care planning for a right foot infection despite prescribed antibiotics and ongoing pain, and absence of a podiatry consult or appointment. The representative also reported being denied access to daily nursing staff information until they produced POA documentation, complaints of increasing spasms and ear pain that were reported to the physician without resolution by a later date, and being told that a specific chair to get the resident out of bed was unavailable even though the representative observed the chair in the hallway outside the room. Further grievances described concerns about rodents in the resident’s room, multiple infections acquired within one month (bedsores, UTI, right foot infection, possible finger infection, and apparent infections in both ears), and a request for a meeting with the complete care team due to concerns that a comprehensive care plan meeting all of the resident’s needs had not been developed and implemented. Record review showed that the facility’s Complaint/Grievance Forms state that a facility representative will review and contact the complainant within 72 hours, and that the bottom portion of the form is to be completed by the facility representative, including findings, how the issue was resolved, referral information, date received, and date shared with the complainant. For this resident, the facility completed only the findings and resolution sections and the forms were signed by a Grievance Officer (signature unknown to staff) and by NHA #1, all dated 2/6/2025, even though NHA #1’s hire date was 2/24/2025. The sections for “Referred to,” “Date Form Received,” and “Date shared with the person filing the complaint/grievance” were left blank. The resident representative reported that the facility never acknowledged receipt of the grievances, did not inform them of the progress of any investigation, and did not share findings or resolutions. The DON confirmed the grievance process as written, but could not explain the documentation discrepancies or the lack of acknowledgment and communication, and documentation of a written decision to the resident representative, as required by the facility’s Resident and Family Grievances policy, was not provided.
Failure to Follow Physician Orders for Wound Care and Timely Medication Administration
Penalty
Summary
The deficiency involves failure to provide treatment and care according to physician orders and resident needs for wound care and medication administration. For one resident with a left leg wound, the surveyor observed on two separate occasions that the wound dressing bore the same date, indicating it had not been changed for six shifts over a two-day period. The dressing was ordered by the primary physician to be changed daily on the day shift, and there was also an order for diabetic foot care checks requiring nursing staff to assess the resident’s feet and ankles. Documentation showed staff had signed off that they performed these checks, which would have required them to see the date on the dressing, yet the dressing remained unchanged. The DON acknowledged that the dressing should have been changed according to the physician’s order. The deficiency also includes failure to administer medications as ordered for another resident. Review of the medical record and MAR audit showed that multiple medications, including oxybutynin, midodrine, tizanidine, and Eliquis, were documented as given several hours after their scheduled administration times on two separate days. There was no documentation that any of these medications were held per physician order, refused by the resident, or delayed for a clinical reason, and no documentation that the physician was notified of the delayed administration. During interviews, the nurse involved and the DON were unable to provide any reason or supporting documentation explaining the late administration times recorded on the MAR.
Failure to Administer PRN Pain Medication Prior to Wound Care
Penalty
Summary
A resident receiving wound care experienced inadequate pain management when a nurse performed a wound dressing change without administering ordered pain medication beforehand. During an observed dressing change, the resident stated they had requested pain medication at 2:30 PM but had not received it prior to the start of the procedure. The nurse explained that she had been performing another resident’s dressing change and therefore did not provide the medication before beginning this resident’s wound care, then asked if the resident was in pain; the resident replied that they were in pain all the time. Review of the clinical record showed a physician’s order for Oxycodone 15 mg by mouth every 4 hours as needed for pain rated 5–10 on a 1–10 scale. In an interview, the DON confirmed that the pain medication should have been administered prior to the wound care. These findings were based on resident interview, staff interview, direct observation of the wound dressing change, and review of the resident’s clinical record.
PRN Oxycodone Administered Outside Ordered Pain Parameters
Penalty
Summary
Facility staff failed to ensure that a resident’s pain medication was administered according to the physician’s order, resulting in multiple doses of Oxycodone being given outside the prescribed parameters. The physician’s order dated 2/4/26 specified Oxycodone 15 mg by mouth every 4 hours as needed for pain rated 5–10 on a 1–10 scale. Review of the Medication Administration Record showed that on 2/6/26 at 8:25 PM; 2/10/26 at 10:37 AM and 5:55 PM; 2/11/26 at 1:50 AM; 2/13/26 at 9:17 PM; 2/14/26 at 1:30 AM and 6:05 AM; and 2/15/26 at 4:33 PM and 8:55 PM, the resident’s pain level was documented as 4, yet the Oxycodone was administered. These administrations did not comply with the physician’s order limiting use of the medication to higher pain scores. During an interview, the DON was informed of these findings and acknowledged that the medication should not have been administered under those circumstances.
Failure to Provide Routine and Follow-Up Dental Services
Penalty
Summary
Facility staff failed to ensure residents received required routine and follow-up dental care, resulting in missed or delayed dental assessments and services. One resident was observed during the initial tour to have few, if any, teeth, and review of the clinical record showed no dental consult in over a year, despite the requirement for at least an annual inspection of the mouth and jaw and diagnosis of any dental disease. When interviewed, the DON confirmed that there was no documentation of a dental consult or examination in the record and that the resident had not been seen by a dentist or dental company since 2023. Another resident with missing teeth and cavities had no clear documentation of routine dental services since admission. The record showed multiple attempted and completed dental encounters: an attempted visit where the resident was not found in the room or hallways, a completed dental exam with notation for a next-visit prophylaxis, and a later attempted dental hygiene encounter that could not be completed due to isolation. There was no documentation that this missed hygiene visit was rescheduled. A change in condition note documented that a left upper molar tooth came out while the resident was talking, with no bleeding or pain noted, and the resident was ordered to be seen by dental services. The last documented dental visit occurred after this tooth loss, and the surveyor identified that the recommended dental hygiene appointment had not been rescheduled following the missed visit.
Unassessed Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that Resident #97 had been assessed for the safe self-administration of magnesium citrate and failed to ensure the interdisciplinary team was aware that the resident was keeping the medication in the room. During the surveyor’s observation, the resident retrieved a bottle of magnesium citrate from a drawer that had a prescription label on it and stated that the medication was kept for emergencies related to constipation and that more had been requested weeks earlier but not provided. The resident also stated that the medication was kept in the room for use as needed. An LPN supervisor told the surveyor that the resident liked to keep personal items and that the magnesium citrate was left with the resident to use when constipated, and the surveyor observed the LPN remove the bottle from the room after the concern was raised. The medical director stated that the resident was confused about the medication and believed it was always available in the medication cart, and was unaware that the resident had the medication in the room. Review of the medical record found no medical order or documentation of an assessment for self-administration of medications for Resident #97.
Failure to Provide Signed Quarterly Personal Funds Statements
Penalty
Summary
Facility staff failed to provide Resident #104 with a quarterly statement for the resident’s personal funds account. During an initial interview, Resident #104 stated that they do not receive a quarterly statement showing the balance in the personal funds account. During a later interview, Staff #18 was asked to provide copies of the quarterly statements signed by Resident #104 to show receipt of the statements, but the signed statements were not provided at the exit conference. Copies were later emailed to the survey team, but they were not signed. This was identified for 1 of 2 residents reviewed for a personal funds account.
Poor Room Cleanliness and Maintenance
Penalty
Summary
The facility failed to ensure resident rooms and furnishings were clean, well maintained, and in good repair. During the initial tour, a nightstand in one resident room was observed to be broken at the base with worn wood stain and a white substance smeared across a drawer front. The same room also contained a wooden dresser with multiple worn and chipped areas, a metal heat unit with gray scrapes and rust-colored areas, broken wall and cove molding, and wall damage with holes, scrapes, and a bubbled appearance. The surveyor noted that the heat unit and bedside nightstand were visible from the hallway. Additional observations showed flooring in another resident room with numerous scrape marks and white staining, and a resident reported that a walker was scraping the floor and that staff had attempted to clean the area without resolving the concern. In another resident room, crumbs and trash were observed on the floor, a strong urine odor was present, and the resident stated the bed was wet and had not been changed when the resident planned to get back into bed. In a separate room, the surveyor observed a hole in the drywall behind the door, scratched wall areas, and scraped and chipped wall damage near the entrance; the Unit Manager confirmed the findings and stated it was a problem.
Resident personal funds were taken and not properly documented
Penalty
Summary
The facility failed to ensure Resident #4’s personal funds were appropriately managed. During interview, Resident #4 stated they had received a Social Security disability back payment check for $19,780.00 made payable only to them, but reported that the Administrator took the check and told them it was used to pay for care at the facility. Resident #4 stated they did not understand why the check was taken when it was not made payable to the facility, and said they wanted to use the money to move back into the community. Resident #4 also reported they were told approximately $2,000.00 had been placed into an account for them, but they did not receive statements or other information about it. Facility leadership stated the income was owed to the facility because the resident had been on Medicaid and had not been approved right away for disability. The Regional Director of Operations reported that the personal needs allowance was subtracted and that about $2,000.00 was placed in a resident fund management service account. Surveyors requested billing statements for the resident’s care, RFMS account statements, documentation showing the funds were issued to the resident, the front and back of the check, and documentation of notification to Medicaid, but the facility did not provide the requested records by the exit conference. The Social Security award letter reviewed by surveyors documented that the resident was to receive $19,780.00 around October 8, 2025.
Failure to Provide Written Transfer/Discharge and Bed-Hold Notifications
Penalty
Summary
The facility failed to provide written information regarding hospital transfers and discharges, including notice to the resident and/or responsible party and the local Ombudsman, for 6 of 6 residents reviewed for transfer/discharge. The report states that written documentation of the transfer or discharge and bed-hold policy was not properly completed or could not be verified for residents #94, #181, #179, #12, #140, and #7. In several cases, the facility could not show that the resident or responsible party received a written copy of the transfer/discharge form, and it also could not verify that the Ombudsman was notified. For resident #94, who had cognitive impairment and was not their own responsible party, the facility provided a Notice of Acute Emergent Discharge or Transfer Form and a Bed Hold form after the resident was transferred to the hospital, but the forms were incomplete. The transfer form had no area for resident or RP signature and was not signed by the RP, and the Bed Hold form did not list the resident name or payment amount and had a blank patient/RP signature line. The DON stated the nurse was responsible for completing the form and getting another person to sign it, but the facility could not provide documentation that the resident and/or RP received the written notice, and the DON confirmed the Ombudsman did not receive written notice of the transfer. Additional record reviews showed the facility could not verify Ombudsman notification for resident #181’s hospital transfer and resident #179’s discharge. For resident #12, the record showed a hospital transfer, and the DON stated certain documents should accompany a resident, but the review of the transfer documentation did not show several listed items were sent, including comprehensive care plans, a current medication list or MAR, a printed vaccination record, the most recent H&P, and a recent hospital discharge summary. For resident #140, who was cognitively intact, the record did not show written discharge/transfer documentation was provided, and the resident stated the form was never received or offered. For resident #7, who had severe cognitive impairment, the record also did not show the responsible party received written discharge/transfer documentation, and the DON could not explain why the RP was not provided the form at the time of transfer.
Late MDS Assessments
Penalty
Summary
The facility failed to ensure resident MDS assessments were completed and transmitted within the required timeframe for 2 of 2 residents reviewed for the Resident Assessment task. For Resident #34, the annual MDS had an assessment reference date of 1/10/26, but the MDSC-RN reported that it was signed late on 2/10/26 and later stated that it was both signed and submitted late. The record showed signatures in section Z0400 by the MDSC-RN dated 2/10/26 and by the RDCS dated 2/22/26, with section Z0500 also signed by the RDCS on 2/22/26. The MDSC-RN stated the assessment should have been completed within 14 days of the assessment reference date and acknowledged it was not completed within that timeframe. For Resident #17, the annual MDS had an assessment reference date of 1/23/26. The record showed signatures in section Z0400 by the MDSC-RN dated 2/20/26 and by an LPN dated 2/19/26, with section Z0500 signed by the MDSC-RN on 2/20/26. During interview, the MDSC-RN stated the assessment should have been completed by 2/5/26 and locked by 2/19/26, and reported that signing is not locking and that the assessment was locked and submitted on 2/24/26, which was late. These findings were reviewed with facility leadership during the exit conference.
Medication Administered From Bottle Labeled for Another Resident
Penalty
Summary
The facility failed to administer medication according to professional standards of practice for one resident observed during medication administration. During observation, an RN prepared Vitamin B-1 100 mg for the resident by retrieving it from a medication bottle that had a pharmacy label with another resident's name on it. The RN stated the medication was being used as house stock and was the same medication, route, and dosage ordered for the resident, but also stated they did not know why the pharmacy labeled the house stock bottle with another resident's name. During interview, the ADON/IP stated that medications, including those considered house stock, that are labeled for a specific resident must not be used as house stock for other residents because that means the medication was dispensed by the pharmacy for that specific resident.
Resident Left Unattended During Coughing Episode and Found on Floor
Penalty
Summary
The facility failed to ensure that a resident was kept safe and free from accidents after the resident was observed in distress. Resident #2 had diagnoses including tracheostomy, epilepsy, and gastrostomy, and was identified in the care plan as being at risk for falls related to a history of falls, poor safety awareness, and strong cough reflexes. During the incident, a nurse was administering medications through the resident’s gastrostomy tube and noted a strong cough reflex. The nurse then went to the medication cart to check whether nebulizer medication was due and, while outside the resident’s door, heard a loud noise from the room. When the nurse returned, Resident #2 was found on the floor mat on the left side with Barri bed bolsters in place, and the resident had a laceration to the left corner of the eye, above the left eyebrow, and bruising to the corner of the left eyelid. The DON confirmed that the resident had a tracheostomy tube and was coughing at the time, and stated that suctioning equipment was kept at the bedside and that the resident should not have been left unattended during that time. The DON also confirmed that the care plan directed staff to ensure the resident’s safety during episodes of strong cough reflex.
Incomplete and inaccurate resident records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for residents #94, #97, and #165. During observation rounds, resident #94 complained of ongoing pain for approximately two weeks, and the nurse was made aware of the concern. Review of the record showed an order for Morphine Sulfate Concentrate 0.25 ml every 4 hours as needed, with doses given at 0446, 0943, and 1429, but the MAR did not document the resident’s pain level as assessed before each administration. For resident #97, the surveyor interviewed the resident about money taken from the resident’s account to purchase clothing. The Activities Director stated that clothing had been purchased, returned, and replaced, and that the resident had received the replacement jeans. However, review of the hard chart showed only one inventory sheet dated earlier and it did not reflect any clothing items received since that date. The resident’s funds account statement showed a clothing purchase of $70.94, and receipts provided by the facility showed clothing purchases in October and November of 2025, but there was no updated personal inventory documentation to reflect the recent purchases. For resident #165, the surveyor found two completed MOLST forms in the paper chart, each signed and dated on different dates. An LPN confirmed that both forms were present and stated that the most recent MOLST should be used in an emergency, but the older form should have been voided. The UM also stated there should be only one MOLST form in the record and confirmed the older form should have been voided. The DON and RVPO were informed of the finding during the survey.
Housekeeping and Maintenance Deficiencies
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for residents on the Somerset and Arcadia Memory Care units. On Somerset, surveyors observed dirty clothing on a resident’s bedside table, a strong urine odor in the room, a central supply cart with a large dark stain, clothing piled in a corner between closets, a bathroom with a dark yellow sticky substance and urine odor, a dresser drawer hanging off its track, and chipping wood behind a resident’s headboard. Staff #21 observed these findings with the surveyor and stated housekeeping would be notified. On Arcadia Memory Care, surveyors observed several dark black stains in the hallway floors, dark black substance at multiple resident room entrances, a shower room door lock with chipped wood and a broken interior lock, a cracked toilet at the base with wet flooring around it, a second shower room with a large bag of dirty clothing and paper towels, masks, and toilet paper scattered on the floor, and ceiling tiles throughout the unit with a large brown substance. Staff #30 toured the unit with the surveyor, verified the findings, and stated housekeeping and maintenance would be notified. In addition, the glass door in the main dining area had several elongated cracks in the glass pane, and the Food Service Manager observed and acknowledged the concern.
Failure to Administer Medications on Schedule
Penalty
Summary
A resident reported receiving medications several hours late. Review of the resident's Medication Administration Audit Report confirmed that multiple morning medications, including Metamucil, Lasix, Buspirone, Lamotrigine, Bactrim DS, and Mounjaro, were administered significantly later than their scheduled times. Specifically, medications scheduled for 9:00 AM were given between 11:37 AM and 2:23 PM on the same day. During an interview, the Director of Nursing acknowledged that the medications were documented as being administered late and stated that while it is possible the medications were given on time but documented late, the expectation is for medications to be administered and documented at the scheduled time. The findings were based on resident interviews, record reviews, and staff interviews, confirming that the facility failed to ensure medications were administered in accordance with professional standards of practice.
Mice Infestation on Third Floor Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mice infestation on the third floor, affecting six residents. Observations revealed no mice traps in residents' rooms, workstations, or breakrooms. Interviews with staff and residents indicated that mice were seen frequently, causing fear and sleepless nights among residents. The facility's policy to provide a safe environment was not upheld, as evidenced by the presence of mice and unsealed gaps in the walls. Residents reported seeing mice in their rooms, with some residents bringing their own traps due to the facility's inaction. The Director of Maintenance was unaware of the residents' concerns, and the pest control log showed visits from a pest control company, but no traps were placed in the facility except in the ceilings. The Director of Nursing acknowledged residents' concerns, but no effective measures were taken to address the infestation. Interviews with staff revealed a lack of awareness and action regarding the mice problem. The Administrator and Director of Maintenance confirmed the presence of mice and visible entrance points, yet no comprehensive pest control measures were implemented. The facility's failure to address the infestation led to ongoing distress and fear among residents, compromising their comfort and safety.
Failure to Maintain Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for four residents, leading to potential exposure to contaminated respiratory equipment and improper airflow. Resident 18, who was admitted with pneumonia and COPD, had a dusty oxygen concentrator that was not cleaned as per the facility's policy. The Assistant Director of Nursing (ADON) confirmed the dustiness but was unaware of the cleaning frequency required for the concentrators. Resident 22, admitted with obesity and congestive heart failure, also had a dusty oxygen concentrator and filter with a significant dust buildup. Licensed Practical Nurse (LPN) 1 verified the condition but did not know the cleaning schedule. Similarly, Resident 120, with COPD and asthma, had a dusty oxygen concentrator and filter, which was confirmed by LPN1 and the Director of Nursing (DON), both of whom were unaware of the cleaning requirements. Resident 357, admitted with a traumatic subdural hemorrhage, had an oxygen mask and tracheostomy collar improperly stored on a bedside table and machine hook, respectively. LPN4 and the ADON acknowledged the improper storage, with the ADON stating that such equipment should be stored in a clean plastic bag. The DON added that if left out of a bag, the equipment would need replacement.
Medication Administration Supervision Deficiency
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for three residents, leading to potential risks of unwarranted medication side effects and mismanaged medical conditions. Resident 122, who was severely cognitively impaired and dependent on staff for daily activities, was left with a medication cup containing approximately 10 dosage forms on a bedside table. The nurse documented the administration of medications before the resident actually took them, contrary to the facility's policy requiring observation of medication consumption. Resident 97, with intact cognition but a history of refusing medications, was found with a medicine cup containing eight pills left unattended in the room. The resident had no order to self-administer medications, and there was no assessment of the resident's ability to store or self-administer medications safely. The nurse admitted to leaving the pills unsupervised, which was against the facility's policy. Resident 103, who had moderate cognitive impairment, was found with bottles of Claritin and Citrical on the bedside table without orders for these medications. The resident was not capable of self-administering medications, and the medications were likely brought in by the resident's daughter. The facility's policy requires medications to be administered by nursing staff and not stored in the resident's room without a physician's order.
Inadequate Grievance Investigation and Documentation
Penalty
Summary
The facility failed to adequately document and investigate a grievance filed by a resident's family member, which involved allegations of verbal threats made by a Certified Nurse Aide (CNA) towards the resident. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reported feeling threatened by the CNA's comments following a state agency complaint investigation. The grievance was filed by the resident's family member, who expressed concerns about the CNA's attitude and potential for retaliation. The grievance documentation was incomplete, lacking specific allegations and details provided by the family member. The Somerset Unit Manager (SUM) only interviewed the resident and did not inquire specifically about the CNA or interview other residents who had received care from the CNA. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) and the Director of Nursing (DON) acknowledged that the grievance was not thoroughly investigated, and additional residents should have been interviewed as part of the investigation. The facility's policy on resident and family grievances requires thorough documentation and investigation of grievances, including taking immediate actions to prevent further potential violations of resident rights. However, the facility did not adhere to this policy, as evidenced by the lack of a comprehensive investigation and failure to address the specific allegations of verbal threats made by the CNA. The family member expressed dissatisfaction with the facility's resolution, which involved reassigning the CNA to a different unit without addressing the potential for further abuse or retaliation.
Failure to Provide Meaningful Activities for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure an ongoing program of meaningful activities for a resident with severe cognitive impairment, dementia, anxiety, and insomnia. The resident was assessed to have a Brief Interview for Mental Status score of zero out of 15, indicating severe cognitive impairment, and was dependent on staff for all activities of daily living except eating. The resident expressed interest in music and religious activities, going outside, and participating in favorite activities, but these preferences were not adequately addressed in the care plan. Observations revealed that the resident was often left alone in their room, facing the wall or the TV, with no music or religious activities provided. The resident was observed singing gospel music when spoken to, indicating an interest in music, yet the care plan did not include music therapy sessions or one-to-one visits. The Activity Director confirmed that the resident preferred to stay in their room and did not leave the unit for activity groups. However, there was no documentation of one-to-one visits or music therapy sessions, and the Activity Director was unaware of the need to document these activities. The facility's policy required an ongoing program to support residents' choice of activities based on their comprehensive assessment, care plan, and preferences. However, the policy was not followed, as the resident's interests in music and religious activities were not adequately addressed, and there was a lack of documentation for the activities provided. The Activity Director acknowledged the need for more frequent music therapy sessions and documentation of activities, but these were not implemented at the time of the survey.
Failure to Apply Splint for Resident's Hand Contracture
Penalty
Summary
The facility failed to ensure a splint was applied to address a hand contracture for a resident, identified as R71, who was reviewed for limited range of motion. R71 was admitted with diagnoses including stroke with resulting hemiplegia and hemiparesis on the left side, muscle spasm, muscle weakness, and vascular dementia. The resident was assessed to be cognitively intact with impaired range of motion on one side of the body. The occupational therapy discharge summary recommended the use of a carrot orthosis at all times except during bathing, but this was not reflected in the resident's care plan or physician's orders. Observations and interviews revealed that R71 had not been using the carrot orthosis for some time, and the resident's left hand was contracted into a fist, causing discomfort and pain. The resident reported that range of motion exercises were no longer performed since therapy discharge, and the splint had not been used for months. The occupational therapist confirmed that the resident's hand seemed tighter and recommended further intervention, such as nerve blocks or consultation with a hand specialist. Interviews with facility staff, including the LPN, unit manager, and director of nursing, indicated a lack of awareness and documentation regarding the use of the carrot orthosis. The facility's policies on prevention in decline in range of motion and use of assistive devices were not consistently followed, as there was no physician's order for the orthosis, and the care plan was not updated to reflect the current needs of the resident. This oversight had the potential to lead to increased contracture, pain, or skin breakdown for the resident.
Failure to Adhere to PPE Protocols for Residents on Precautions
Penalty
Summary
The facility failed to ensure appropriate personal protective equipment (PPE) was worn for two residents under transmission-based or enhanced barrier precautions. For Resident 107, who was diagnosed with recurring clostridium difficile (c-diff), staff members repeatedly entered the resident's room without donning the required gown and gloves, despite a sign indicating contact precautions. Certified Nurse Aides (CNAs) were observed entering and exiting the room without PPE and without performing hand hygiene, indicating a lack of awareness or communication regarding the resident's precautionary status. In the case of Resident 205, who required enhanced barrier precautions due to multiple pressure ulcers, a gastrostomy tube, and an indwelling urinary catheter, a Licensed Practical Nurse (LPN) was observed administering medications via the gastrostomy tube while only wearing gloves, contrary to the facility's policy that required a gown for such procedures. The LPN misunderstood the need for a gown, believing it was only necessary for urinary catheter care, despite the posted instructions for enhanced barrier precautions. Interviews with staff revealed a lack of understanding and communication regarding the necessity of PPE for residents on contact or enhanced barrier precautions. The Assistant Director of Nursing/Infection Preventionist and the Director of Nursing confirmed the requirements for PPE use, which were not adhered to by the staff. The facility's policies clearly outlined the need for PPE to prevent the transmission of infections, but these were not followed, leading to potential risks of infection spread among residents and staff.
Failure to Revise Care Plan for Medication Refusal
Penalty
Summary
The facility failed to revise the care plan for a resident who had a history of schizophrenia, bipolar disorder, and type 2 diabetes, to include interventions for medication refusals. On a specific date, the resident called 911 because they had not received their insulin all day. A review of the medication administration record showed that the resident had refused their 6:00 AM Levemir injection, which is a long-acting insulin used to control blood sugar levels. Interviews with staff revealed that when the resident refused insulin, the LPN would contact the doctor and encourage the resident to take the medication, sometimes using strategies like offering pudding, which had been effective in the past. However, the care plan did not document these interventions. The surveyor discussed this oversight with the Director of Nursing, highlighting the failure to ensure that the care plan included strategies to address the resident's medication refusals.
Inadequate Supervision Leads to Multiple Falls
Penalty
Summary
Facility staff failed to ensure the safety of a resident by not providing adequate supervision, resulting in the resident experiencing five falls over a four-month period. The resident, who was admitted with diagnoses including delirium, right-side stroke, osteoarthritis, depression, and heart failure, was identified as high risk for falls. Despite having a care plan in place that included interventions such as psychiatric evaluation for restlessness, reinforcement of call bell use, and monitoring every two hours at night, these measures were not effectively implemented. On one occasion, the resident fell and was left on the floor for hours, with the police eventually being called to assist. Interviews with staff revealed that the back hallway corner nurse's station, which was supposed to be monitored during evening and night shifts, was often left unattended. This lack of supervision contributed to the resident's falls, as staff were unaware of the resident's calls for help. The Director of Nursing confirmed the incidents and acknowledged the failure to conduct required rounds, which were part of the care plan interventions. The facility's inability to follow the care plan and provide adequate supervision led to the repeated falls and the resident being left unattended for extended periods.
Ineffective Pest Control Program Leads to Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of mice throughout the building. Numerous reports and observations indicated the presence of mice in various rooms, including patient rooms and common areas. Residents and their families expressed concerns about the mice, with some taking measures such as setting traps in their rooms. The Nursing Home Administrator acknowledged the issue but indicated that resolving it would take time. Documentation from the pest control company and facility logs confirmed multiple sightings and reports of mice over several months, with specific rooms and areas being repeatedly affected. The deficiency was further exacerbated by a lack of proper facility management, as evidenced by an exit door on the ground floor being propped open, allowing easy access for rodents. Despite being informed of this issue, the door continued to be left open, as noted by the Director of Maintenance. This oversight allowed for continued entry of pests into the facility, undermining the efforts of the pest control company. The administrative staff was made aware of these concerns during the exit conference, highlighting the facility's failure to address the pest problem effectively.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse and an injury of unknown origin within the required timeframes to the Office of Health Care Quality (OHCQ). This deficiency was identified during a complaint survey involving three residents across multiple facility-reported incidents. For Resident #10, there were two separate incidents where the resident alleged being smacked in the head by a person drawing blood. In both cases, the facility did not provide the surveyor with the date of the incident or evidence of an investigation, and the reports were not submitted to OHCQ in a timely manner. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unable to locate the investigation files for these incidents. Additionally, the facility failed to report an alleged physical abuse incident involving Resident #8 within the required two-hour timeframe. The initial report was sent to OHCQ late, and no email confirmations were provided to verify the submission time. The DON and the administrator acknowledged the deficiency but could not locate the incident report or the investigation. Another incident involving Resident #2, related to alleged employee-to-resident abuse, was also not reported timely, and the facility investigation could not be found. These failures to report and document investigations highlight significant lapses in the facility's compliance with regulatory requirements.
Failure to Investigate Alleged Incidents
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of alleged abuse, neglect, and misappropriation of property involving several residents. In one case, a resident reported to their spouse that a staff member who drew their blood had smacked them in the head. However, there was no date of the incident on the report, and no investigation was provided to determine the date or details of the incident. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that they could not locate the investigation files related to this incident. Similar issues were found with another incident involving the same resident, where again, no investigation could be found. Another incident involved a resident who reported to the police that someone had taken their purse and struck them with it. The facility was unable to provide the incident report or investigation documentation. Additionally, an alleged employee-to-resident abuse incident was reported, but the facility could not find the investigation. Lastly, a misappropriation of a resident's funds was reported, but the investigation lacked critical details such as room numbers for resident statements and interventions to prevent future occurrences. The Administrator mentioned that a lock-box might have been provided to the resident, but this was not documented in the investigation.
Delayed Wound Care Implementation for Resident with Scrotal Ulcer
Penalty
Summary
The facility failed to timely implement wound care orders for a resident with a scrotal ulcer. The deficiency was identified during a complaint survey, where it was found that a resident, admitted in July 2021 with multiple diagnoses including obstructive and reflux uropathy, dementia, and Down syndrome, developed an ulcer on the dorsal scrotum. The resident was admitted with a Foley catheter due to obstructive and reflux uropathy. On September 28, 2021, the ulcer was noted, but there was no further documentation in the progress notes or skin sheets related to the ulcer. The Treatment Administration Record for October 2021 showed an order for Calmoseptine ointment to be applied to the sacrum and groin every shift. However, treatment for the ulcer was not initiated until October 1, 2021, three days after the ulcer was first noted. During an interview, the Director of Nursing confirmed the lack of documentation regarding the size and description of the ulcer and acknowledged the delay in treatment initiation. The ulcer was reported to have healed within 15 days, and it was suggested that the ulcer was likely caused by the Foley catheter tubing.
Physician's Failure to Timely Sign Progress Notes
Penalty
Summary
The facility staff failed to ensure that the physician wrote, dated, and signed progress notes at each resident's visit, as required by policy. This deficiency was identified during a complaint survey for one resident. The medical record review revealed that the physician's notes for this resident were not signed on the date of the visit. Specifically, notes dated 2/21/24, 2/28/24, 3/6/24, 3/8/24, and 3/13/24 were signed days after the actual visit dates, with delays ranging from several days to nearly a month. The Nursing Home Administrator acknowledged the issue, noting that the physician had moved out of state and was no longer employed at the facility. The facility's policy clearly stated that physicians should date, write, and sign a progress note for each visit, which was not adhered to in this case.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure the availability of pain and anxiety medications for a resident, leading to multiple incidents where the resident was unable to receive prescribed medications. The resident, who had a history of chronic pain syndrome, opioid dependence, cerebral infarction, anxiety disorder, and Parkinson's disease, frequently experienced unavailability of medications such as Oxycontin and Lorazepam. This resulted in the resident calling 911 on several occasions due to the lack of pain medication, as documented in the medical records and complaint reviews. Interviews with the resident and staff revealed that the issue was partly due to agency staff not ordering medications in a timely manner, leading to shortages, especially over weekends. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) acknowledged the problem, noting that the resident's behavior was unpredictable when medications were not available. The DON admitted that medications should be ordered before they run low to ensure they are on hand, but the process was described as an ongoing struggle between the facility and the pharmacy. The facility's Quality Assurance and Performance Improvement (QAPI) plan, initiated in January 2024, aimed to address the medication availability issue. However, the problem persisted, as evidenced by the resident's continued calls to 911 due to medication shortages as recently as September 2024. The Nursing Home Administrator and Corporate Nurse were informed of the ongoing concern, highlighting the facility's failure to maintain a consistent supply of necessary medications for the resident.
Inaccurate and Delayed Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and up-to-date medical records for its residents, as evidenced by the review of two residents during a complaint survey. For one resident, the medical record indicated a discharge to the hospital, but the resident had passed away shortly after. Despite this, an initial activity assessment was uploaded into the resident's medical record after the resident's death, indicating a delay in documentation. This discrepancy was identified during a review of the resident's medical record and confirmed through an interview with the Director of Nursing (DON) and the activity director. For another resident, the medical records contained multiple inaccuracies related to the documentation of vital signs. Several physician notes had vital signs dated incorrectly, not reflecting the actual date of the resident's examination. These inaccuracies were discovered during a review of the resident's medical record, where it was found that the vital signs were dated on the day the resident was transferred to the hospital, rather than the date of the exam. The DON and the Nursing Home Administrator (NHA) were shown these discrepancies, confirming the findings.
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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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