Calvert County Nursing Ctr.
Inspection history, citations, penalties and survey trends for this long-term care facility in Prince Frederick, Maryland.
- Location
- 85 Hospital Road, Prince Frederick, Maryland 20678
- CMS Provider Number
- 215188
- Inspections on file
- 23
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Calvert County Nursing Ctr. during CMS and state inspections, most recent first.
A resident’s motorized wheelchair remained nonfunctional for an extended period despite vendor measurements and an approved authorization, limiting the resident’s mobility and independence. The PT director had a vendor assess the resident and forwarded the estimate to the Administrator during a period when there was no BOM. The BOM, who started later, learned that payer authorization had already been granted, but the facility had not tracked or followed up on the process, and the Administrator acknowledged a breakdown in follow-up and communication with the resident regarding the status of the wheelchair.
A resident reported that an agency GNA provided rough and rude care while repositioning them in bed, including being roughly pulled by the neck and arm. During the facility’s investigation of the incident, two other residents also reported that the same agency GNA was rude and provided rough care. The NHA concluded that the agency GNA had abused the resident.
A facility failed to provide a psychiatric evaluation for a resident with a history of trauma from physical abuse. The resident reported an alleged abuse incident involving an LPN, leading to a recommendation for psychiatric assessment. Despite a trauma-informed care assessment confirming the need, the evaluation was not conducted during the resident's stay, as confirmed by the facility administrator.
A resident at high risk for falls was improperly transferred by a GNA who did not use the required sit-to-stand device, resulting in a fractured arm. Despite the resident and another GNA indicating the need for the device, the transfer was done manually, causing injury. The resident was dependent on staff for transfers, as noted in their MDS assessment.
The facility did not promptly report allegations of staff-to-resident abuse and injuries of unknown origin for four residents, including incidents where an LPN was reported to have thrown medication at a resident and unexplained bruising was found on residents with cognitive impairment. These events were either not reported to the DON or state agency as required, or only discussed informally, contrary to facility policy.
Surveyors found that ice machines in both the kitchen and a unit nourishment room had visible smears, debris, and film on their surfaces. The ADM confirmed the unclean conditions, and interviews revealed unclear staff responsibilities for cleaning. The cleaning log did not specify if the entire machine was cleaned, and relevant policies were not provided.
A resident was prescribed an antibiotic for a UTI without documented signs or symptoms to justify the prescription, and there was no evidence that the facility's antibiotic stewardship program ensured compliance with McGeer Criteria. The Infection Preventionist could not confirm the presence of required clinical indicators due to lack of nursing documentation, and the DON acknowledged the oversight in the review process.
The facility did not provide or document required education and consent or declination for flu and pneumococcal vaccines for several residents, despite administering the vaccines. Residents with chronic conditions such as diabetes, COPD, asthma, heart failure, and vascular dementia were affected. Interviews with the IP and DON revealed confusion about responsibilities and errors in documentation, leading to the deficiency.
A resident with severe cognitive impairment wandered into another resident's room, leading to a confrontation where the latter was pushed and fell. The facility's interventions were insufficient to prevent the incident, despite policies ensuring residents' rights to be free from abuse.
Two residents reported incidents of inappropriate conduct by staff members, but their care plans were not updated to reflect these changes in condition. Despite facility policy requiring care plan reviews after such incidents, no updates were made, as confirmed by the DON and Administrator.
The facility failed to provide trauma-informed care for three residents. One resident disclosed past sexual abuse, but the assessment was not updated. Another resident alleged inappropriate touching, and a third reported being slapped, yet no trauma-informed assessments were conducted. The DON and Administrator confirmed assessments should occur at admission and after changes in condition.
Two residents with injuries of unknown origin did not have their cases investigated as required by facility policy. In both instances, staff observed unexplained bruising, reported the findings to supervisors and clinical staff, but no formal investigation was conducted to determine the cause. The DON and Administrator confirmed that these incidents were not investigated, despite policy requiring prompt reporting and thorough investigation of such events.
A resident with multiple medical conditions did not receive prescribed medications as ordered because the medications were not available from the pharmacy. The LPN documented the medications as on hold and did not check facility stock or notify the physician, as confirmed by the DON.
A registered nurse left a medication cart unlocked and unattended with an insulin pen on top while conducting a blood sugar check for a resident. The cart and medication were out of the nurse's sight as she went into the resident's bathroom, contrary to facility policy requiring medication carts to be locked and medications secured when not in direct view.
Staff failed to protect resident-identifiable information by leaving computers with electronic medical records unlocked and unattended during care tasks. Both a registered nurse and a unit manager left computers open on medication carts, exposing resident information, and later acknowledged this was improper. The DON confirmed this practice was unacceptable.
Staff did not consistently use required PPE when caring for a resident on contact precautions for MSSA infection, and failed to properly handle medications after they were dropped during administration. A nurse provided care without donning PPE, and other staff attempted to administer medications that had been dropped onto unclean surfaces, contrary to facility policy and infection control standards.
The facility failed to update its facility-wide assessment, crucial for resource allocation during emergencies, as identified in a complaint survey. The assessment lacked plans for emerging infections, and interviews revealed that the water management program was outdated and not reviewed by current staff, contributing to the deficiency.
The facility failed to inform residents and families of respiratory illness outbreaks and did not monitor water temperatures effectively, leading to potential infection risks. Despite a meeting to address the respiratory illness, documentation was lacking, and water temperatures in several rooms were below the required level.
Failure to Provide Timely Motorized Wheelchair to Support Resident Independence
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to self-determination and freedom of movement by not providing a functional motorized wheelchair in a timely manner. A resident reported during the complaint investigation that their motorized wheelchair had been nonfunctional since 2025. The resident stated that a vendor had come to complete measurements for repair or replacement, but there had been no follow-up or communication regarding the status of the equipment. The resident reported that the lack of a functioning motorized wheelchair limited their mobility within the facility and affected their independence. Record review and staff interviews showed that the Physical Therapy Director had the resident measured for a motorized wheelchair by Freedom Mobility on 08/18/2025 and forwarded the vendor’s estimate to the Administrator because there was no Business Office Manager (BOM) in place at that time. The BOM, who started in December 2025, stated she became aware of the wheelchair issue on 01/16/2026 and learned from Freedom Mobility that authorization from Telligen had been received on 10/10/2025. The Administrator confirmed that from July 2025 through December 2025 there was no BOM and she had assumed Business Office responsibilities, which led to a breakdown in follow-up and tracking of the authorization process. She acknowledged that the facility did not follow up on the approved request and did not update the resident on the status, resulting in a delay in providing the necessary mobility equipment.
Agency GNA Provided Rough and Rude Care During Repositioning
Penalty
Summary
The facility failed to protect a resident from abuse when an agency GNA provided rough and rude care during repositioning in bed. During an interview, Resident #6 reported that Agency GNA #16 roughly pulled the resident by the neck and arm and was very rude while assisting with repositioning. A review of Facility Reported Incident (FRI) #2736958 showed that, following investigation, the Nursing Home Administrator determined that Agency GNA #16 had abused Resident #6. During the same investigation, two other residents also reported that Agency GNA #16 was rude and provided rough care, supporting the finding that the resident was not kept free from abuse.
Failure to Provide Psychiatric Evaluation for Resident with Trauma History
Penalty
Summary
The facility failed to provide a psychiatric evaluation for a resident who had a history of trauma from physical abuse. During a complaint survey, it was found that the resident reported an allegation of abuse by an LPN, who allegedly threw a cup filled with medication at the resident. Although the facility's investigation could not substantiate the abuse, it recommended a psychiatric assessment for the resident following the incident. A trauma-informed care assessment confirmed the resident's history of physical abuse and the need for psychiatric evaluation. However, a review of the resident's medical records revealed no evidence that the recommended psychiatric assessment was conducted during the resident's stay. The facility administrator confirmed this oversight during an interview.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility staff failed to transfer Resident #417 using a sit-to-stand transfer device, resulting in the resident sustaining a fracture to their right arm. The resident was at high risk for falls, as indicated in their fall prevention care plan. The Minimum Data Set (MDS) assessment showed that the resident depended on staff for transfers and required the support of two or more individuals. On the day of the incident, the resident was preparing to attend an activity when GNA 2 and GNA 3 entered the room to assist with the transfer. Despite the resident and GNA 3 indicating that a sit-to-stand device should be used, GNA 2 opted to manually lift the resident, leading to the injury. The incident report revealed that the resident informed the Director of Nursing that the aide did not transfer her correctly, and the resident experienced pain and heard a snap in her arm during the transfer. GNA 3 confirmed that the resident was a sit-to-stand transfer and offered to retrieve the device, but GNA 2 proceeded with the manual lift due to being in a hurry. The Director of Nursing confirmed that the sit-to-stand lift transfer had been in place since 2022, and GNA 2 did not follow the proper protocol. The resident was subsequently sent to the emergency room for treatment of the fractured arm.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to promptly report allegations of staff-to-resident abuse and injuries of unknown origin for four residents, as required by its own policy and regulatory expectations. In one instance, a cognitively intact resident reported that an LPN was rude and tossed a medication cup onto her roommate's bed, and that a GNA was similarly rude and dismissive when she requested assistance. The resident reported the incident to the Unit Manager, who acknowledged that the incident should have been reported to the Director of Nursing (DON) but was only mentioned informally and not through official channels. Another resident, also cognitively intact, reported to the Unit Manager that an LPN threw her medication cup onto her bed and told her to take what she wanted, which was corroborated by her roommate. The DON admitted that she had not reported the incident because she did not realize it required investigation. In both cases, the facility's policy requiring prompt reporting to authorities was not followed, and the incidents were not officially documented or reported as potential abuse. For two other residents with severe cognitive impairment, staff discovered unexplained bruising and injuries. In one case, a large bruise was found on a resident's left flank, and in another, a bruise was noted on the right eye socket. Staff reported these findings to supervisors and discussed them in clinical meetings, but there was no evidence that the injuries were reported to the state agency as required. Similarly, another resident with severe cognitive impairment was found to have bruising and swelling on the inner thigh, which was reported internally but not to the state agency. Interviews with staff and administration confirmed that these injuries of unknown origin were not reported within the required timeframe, and in some cases, not reported at all.
Ice Machines Not Maintained in Clean Condition
Penalty
Summary
Surveyors observed that the facility failed to maintain cleanliness of the ice machines located in both the kitchen and the Southern Shore unit nourishment room. The kitchen ice machine was found with clear and brownish colored smears, debris on the exterior, and an orangish film on the interior front surface. Similarly, the ice machine in the Southern Shore unit nourishment room had clear and brownish colored smears with debris. The Assistant Dietary Manager confirmed the presence of these smears and debris on both machines. The Maintenance Director stated that maintenance staff cleaned the inside of the machines while kitchen staff cleaned the exterior, but the cleaning log only documented quarterly clean-outs and filter changes without specifying if the entire machine was cleaned inside and out. The DON was unsure who was responsible for cleaning the ice machines, noting that it had been a group effort involving maintenance, kitchen, and housekeeping staff. Requested policies regarding ice machine cleaning were not provided before the end of the survey. This deficiency had the potential to affect 97 of 98 residents in the facility, as noted by the surveyors.
Failure to Implement Functional Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a functional Antibiotic Stewardship Program in accordance with its own policy and the McGeer Criteria for antibiotic prescribing. Specifically, a resident with diagnoses including diabetes mellitus and morbid obesity was prescribed Ciprofloxacin for a urinary tract infection (UTI) without documented evidence of signs or symptoms that would warrant the collection of a urine specimen or the initiation of antibiotic therapy. The resident's electronic medical record showed a urine specimen was collected, but there was no prior documentation of a change in condition or physician order for the specimen collection. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed that the required review of the resident's chart to ensure compliance with McGeer's criteria was not performed. The IP was unable to confirm whether the resident met the necessary clinical criteria for a UTI, as the nurse had not documented any relevant signs or symptoms. The DON acknowledged that it is the IP nurse's responsibility to review each antibiotic order for compliance, indicating a lapse in the facility's antibiotic stewardship process.
Failure to Provide Vaccine Education and Obtain Consent for Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide required education and obtain consent or declination for influenza and pneumococcal vaccinations for four out of five sampled residents, as identified through record review, interviews, and facility document review. According to the facility's own policies and CDC guidelines, residents or their representatives should receive education about these vaccines, and documentation of education, consent, or refusal must be maintained in the medical record. However, for the residents reviewed, there was no documented evidence that education was provided or that consent or declination was obtained for either the flu or pneumococcal vaccines. Specifically, one resident with diabetes mellitus and chronic obstructive pulmonary disease received a flu vaccine and previously refused a pneumococcal vaccine, but there was no documentation of education or offer of the pneumococcal vaccine since a prior date. Another resident with asthma and myocardial infarction received a flu vaccine, but there was no evidence of education or offer of the pneumococcal vaccine. A third resident with atrial fibrillation, a stage four pressure ulcer, and hypertension received both vaccines at different times, but again, there was no documentation of education or offer of the pneumococcal vaccine since admission. The fourth resident, with heart failure, atrial fibrillation, and vascular dementia, also received both vaccines, but lacked documentation of education or offer of the pneumococcal vaccine since admission. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) revealed confusion regarding responsibilities for providing education, obtaining consent, and documenting these actions. The IP stated that education and consents were provided but admitted to erroneously marking forms in a way that indicated education or offers were not made. This lack of proper documentation and process adherence resulted in the identified deficiency.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 57, who was severely cognitively impaired with a BIMS score of zero, wandered into Resident 58's room. Resident 58, who was not cognitively impaired with a BIMS score of 12, became startled and yelled at Resident 57 to leave. Due to limited impulse control from dementia, Resident 57 shoved Resident 58, causing her to fall. The incident was witnessed by staff, and Resident 58 reported pain in the back of her head but was stable and able to walk with a cane after being assisted up. The facility's policy on abuse and neglect states that residents have the right to be free from abuse by anyone, including other residents. However, the facility's interventions for Resident 57, who was known to wander and become confused about room locations, were insufficient to prevent the incident. Staff had to redirect Resident 57 frequently, and a sign was put up after the incident to help him identify his room. The Director of Nursing at the time of the report was not aware of the incident, as she was not in the position when it occurred.
Failure to Update Care Plans After Allegations of Abuse
Penalty
Summary
The facility failed to update the care plans of two residents following allegations of inappropriate conduct by staff members. Resident #406 reported being touched inappropriately by a male GNA, as documented by a hospice volunteer. Despite the allegation, a review of the resident's medical record revealed no evidence of any changes made to the care plan to address this change in condition. Interviews with the Social Work Director and nursing staff confirmed that the facility's policy requires a review and update of the care plan following such incidents, but this was not done in this case. Similarly, Resident #407 alleged being slapped in the face by a staff member, as reported to the resident's spouse. A review of the medical record showed no updates to the care plan following this allegation. The Director of Nursing and the Administrator acknowledged that the care plan should have been reviewed and updated in response to the change in condition, but confirmed that no such changes were made. These findings were identified during a complaint survey conducted by the State of Maryland's Office of Health Care Quality.
Failure to Implement Trauma-Informed Care
Penalty
Summary
The facility failed to develop and implement a process to ensure that residents with a history of trauma received appropriate trauma-informed care. This deficiency was identified for three residents. Resident #421 felt uncomfortable during a bath by a Geriatric Nursing Assistant, and later disclosed a history of sexual abuse, which was not updated in the trauma-informed care assessment. The Director of Social Work acknowledged the oversight in updating the assessment after the resident revealed the trauma. Resident #406 alleged inappropriate touching by a male staff member, but no trauma-informed care assessment was conducted following the allegation. Similarly, Resident #407 reported being slapped by a staff member, yet there was no evidence of a trauma-informed care assessment after the incident. Interviews with the Director of Nursing and Administrator confirmed that trauma-informed assessments should be conducted at admission and after any change in condition, but these were not completed for the residents involved.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for two residents who were reviewed for abuse. For one resident with severe cognitive impairment, a nurse discovered swelling and bruising on the right inner thigh during medication administration. The incident was reported to the on-call advanced practice nurse, the resident's daughter, and the supervisor, but no investigation was conducted to determine the cause of the injury. Both the DON and the Administrator confirmed during interviews that the incident was not investigated, despite acknowledging that it should have been. For another resident, who had no cognitive impairment, staff observed a bruise on the left flank during routine care, and the resident exhibited discomfort. The bruise was reported to the unit manager and discussed in clinical meetings, but staff were unable to determine the cause. Additionally, a bruise to the right eye socket was noted, which the unit manager did not report immediately, believing it was not severe. The DON and Administrator both confirmed that these injuries were not investigated, and documentation regarding the determination of the cause was not provided. The facility's policy requires all injuries of unknown origin to be promptly reported and thoroughly investigated, which was not followed in these cases.
Failure to Provide Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident's prescribed medications were available and administered according to the physician's orders. The resident, who was admitted with diagnoses including complete intestinal obstruction, surgical aftercare, and hypertension, had orders for Pramipexole Dihydrochloride ER for restless leg syndrome and carvedilol for hypertension. Review of the Medication Administration Record showed that Pramipexole was marked as on hold for several consecutive days, and carvedilol was also marked as on hold on one occasion. Documentation indicated that the medications were not available from the pharmacy during these times. During interviews, the LPN responsible for administering the medications stated uncertainty about why the medications were documented as on hold, but suggested it was likely due to the medications not being received from the pharmacy. The LPN also indicated that they did not check the facility's stock for available medications. The Director of Nursing confirmed that if the medications were not present, the nurse should have notified the physician, but there was no confirmation that this occurred.
Medication Cart Left Unlocked and Unattended During Medication Pass
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to secure a medication cart during a medication pass. The RN left the medication cart unlocked and unattended outside a resident's room, with an insulin pen placed on top of the cart. While the RN was inside the resident's bathroom, both the cart and the medication were out of her sight. This action was observed during a blood sugar check for the resident. Facility policies require that medication carts be locked at all times when not in the nurse's view and that all drugs and biologicals be stored securely. The RN confirmed during an interview that she had left the cart unlocked with the insulin pen on top, acknowledging that she should have secured the medication. The Director of Nursing also stated that the expectation is for medications to be securely stored and carts to be locked when not within staff sight.
Failure to Safeguard Electronic Medical Records
Penalty
Summary
Facility staff failed to safeguard resident-identifiable information in accordance with their policy on electronic medical records. During a blood sugar check, a registered nurse left a computer unlocked and unattended on top of the medication cart, exposing resident information while washing hands in a resident's bathroom. The nurse confirmed the computer was left open and acknowledged this was improper. In a separate incident during a medication pass, a unit manager left the computer open with resident information visible on the medication cart while leaving to obtain cups, with the computer out of reach and sight. The unit manager also acknowledged the failure to lock the computer. The Director of Nursing confirmed that exposing protected health information was unacceptable.
Failure to Follow Infection Control Protocols and Safe Medication Handling
Penalty
Summary
Staff failed to follow appropriate infection prevention and control protocols for a resident on contact precautions due to a methicillin-susceptible Staphylococcus aureus (MSSA) infection. The resident, who was cognitively intact and had a history of MSSA bacteremia, pneumonia, and congestive heart failure, was placed on contact isolation as indicated by physician orders and facility policy. Despite clear signage and policy requirements for the use of gowns and gloves upon entering the resident's room, a registered nurse entered the room and connected intravenous antibiotics to the resident's PICC line without donning any personal protective equipment (PPE). When questioned, the nurse stated a belief that PPE was unnecessary because the resident's infection was limited to the lungs, which contradicted both the facility's policy and the infection control preventionist's instructions. Additionally, staff did not adhere to infection control procedures during medication administration. During medication passes, a medication technician dropped a pill onto the medication cart, picked it up with bare hands, and intended to administer it to a resident. In a separate incident, a unit manager dropped a pill onto a piece of paper on the medication cart and then scooped it up with a medication cup, expressing uncertainty about the cleanliness of the paper. Both staff members acknowledged during interviews that these actions were not in line with proper infection control practices, and the director of nursing confirmed that dropped medications should be disposed of and not administered. These observations demonstrate a failure to consistently implement the facility's infection prevention and control policies, specifically regarding the use of PPE for residents on contact precautions and the handling of medications to prevent contamination. The deficiencies were identified through direct observation, interviews with staff, and review of facility policies and resident records.
Deficiency in Facility-Wide Assessment and Water Management Program
Penalty
Summary
The facility failed to revise and document an accurate, up-to-date facility-wide assessment, which is crucial for determining the necessary resources to care for residents during both regular operations and emergencies. This deficiency was identified during a complaint survey, which included a review of the facility's emergency preparedness plan. The assessment did not account for potential emerging infections and illnesses, nor did it include a plan for identifying, treating, and preventing the spread of organisms within the facility. This oversight has the potential to affect all residents in the facility. Interviews with facility staff revealed further issues with the facility's water management program. The Infection Control Preventionist (ICP) confirmed the existence of a water management program but noted a lack of meetings or discussions regarding water-based infections or risk assessments. The director of maintenance acknowledged that the water management plan was developed under a previous administrator but admitted that the current staff has not reviewed the plan since its creation. These inactions contributed to the facility's failure to maintain an effective and updated facility-wide assessment.
Infection Control Deficiencies in Respiratory Illness Notification and Water Temperature Monitoring
Penalty
Summary
The facility failed to maintain an effective infection control program by not informing residents, their representatives, and families of the occurrence of three or more residents or staff with new onset of respiratory symptoms within 72 hours of each other. This was evident on three different occasions in June 2024. Despite the facility administrator meeting with staff and residents on June 21, 2024, to discuss precautions for a respiratory illness, there was no documentation of resident and staff attendance at this meeting. The health department was first informed of the pneumonia outbreak on June 6, 2024, after two cases were identified on June 5, 2024, and the facility remained on outbreak status as of June 26, 2024. Additionally, the facility did not ensure consistent infection prevention monitoring for waterborne infections, as evidenced by low resident hand sink water temperatures. During a walking tour, it was found that seven rooms on the East Wing had hot water temperatures below the required minimum of 100 degrees Fahrenheit. The maintenance department's records showed that the hot water temperatures were consistently below the required level on several days in June 2024. The assistant director of maintenance confirmed that individual resident room temperatures were not measured, and the recorded temperatures were taken from the facility boiler room.
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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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