Carriage Hill Bethesda
Inspection history, citations, penalties and survey trends for this long-term care facility in Bethesda, Maryland.
- Location
- 5215 Cedar Lane, Bethesda, Maryland 20814
- CMS Provider Number
- 215234
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Carriage Hill Bethesda during CMS and state inspections, most recent first.
A resident who was cognitively intact, as evidenced by a BIMS score of 14, had previously told facility staff that he/she did not want to apply for Medicaid and planned to return home. Despite this, facility leadership and the business office submitted a Medicaid application without the resident's knowledge or consent, designating the case as an applicant without a representative who lacked capacity to appoint one. This misrepresented the resident's decision-making capacity and failed to honor the resident's right to refuse services and direct his/her own personal and financial affairs.
Pharmaceutical services failed to verify correct indications for antiepileptic medications prescribed to a resident. The MAR listed Depakote for seizures and Lamotrigine for epilepsy, yet review of the medical record showed no history or current diagnosis of seizures or epilepsy. A staff member confirmed the absence of such diagnoses in the chart and could not explain how the facility or pharmacy ensured that the indications documented for these medications were accurate.
A resident’s MAR and physician orders showed that acetaminophen was administered in amounts exceeding the ordered 3 g/24 hr maximum when both scheduled and PRN doses were given on the same days. The same resident had PRN orders for oxycodone 5 mg q6h for mild to moderate pain and oxycodone 7.5 mg q6h for severe pain rated 7–10, yet received oxycodone 7.5 mg doses before the 6‑hour interval elapsed and for pain scores below the ordered severity range. Facility staff, upon review with surveyors, acknowledged these administrations as medication errors.
A resident was found to lack access to both a phone and a working TV remote in a semi-private room. Staff confirmed there was only one phone jack in the room, with the single phone line connected to the roommate’s phone, and that the resident did not have a personal or facility-provided phone. Staff reported the resident sometimes used the roommate’s phone for private communication with family. During observation, the Maintenance Director was unable to operate the TV with the resident’s remote and had to turn the TV on manually, confirming the remote was not functioning.
The facility failed to complete and transmit MDS assessments for 27 residents within the required timeframe. The delay was due to increased admissions and a reduction in staff responsible for MDS assessments. The facility prioritized Medicare assessments, leading to delays in others. The issue was acknowledged by the Lead MDS Coordinator and reported to the NHA and DON.
The facility failed to maintain safe hot water temperatures, with several resident bathroom sinks exceeding the maximum allowable limit. Despite weekly monitoring and a mixing valve set at 118 degrees Fahrenheit, temperatures were recorded as high as 128.2 degrees Fahrenheit. The Maintenance Director could not explain the discrepancy, posing a potential risk to all residents.
The facility failed to ensure a homelike environment and accommodate resident needs, as observed by surveyors. Environmental concerns such as stained ceiling tiles, missing call bell cords, and a covered smoke detector were noted. Additionally, a resident experienced discomfort due to an air mattress not ordered by a physician, which was not promptly addressed despite complaints.
The facility failed to complete MDS assessments within the required timeframe for six residents, with some assessments being over 30 days overdue. The Lead MDS Coordinator cited increased admissions and reduced staffing as reasons for the delay. The NHA and DON were informed of these findings.
The facility did not complete Quarterly MDS assessments within the required timeframe for 18 residents. The delay was due to increased admissions and a reduction in staff responsible for assessments, leaving only the Lead MDS Coordinator and an LPN to handle the workload. The NHA and DON were informed of the issue.
The facility failed to provide invitations and conduct care plan meetings for several residents, leading to deficiencies in care plan documentation and updates. A resident with moderate cognitive impairment was not invited to meetings, and another resident's care plan was not updated to reflect current dialysis access. Additionally, two residents had only one documented care plan meeting over extended periods, with the facility acknowledging the lack of documentation and late status of meetings.
The facility failed to maintain accurate medical records and documentation for several residents, including discrepancies in activity participation records, medication administration, and Medical Orders for Life-Sustaining Treatment (MOLST) forms. A resident did not receive prescribed medication for ten days, and another was observed without the ordered air mattress. Additionally, MOLST forms inaccurately reflected residents' cognitive statuses.
A resident was neglected during an entire shift, resulting in soaked bed linens and significant distress. The resident's call light was on, and they expressed a need to be cleaned. The night shift staff found the resident in this condition, indicating neglect during the evening shift. An LPN documented the incident, and the Director of Nursing acknowledged awareness of the situation.
A facility failed to thoroughly investigate an abuse allegation involving a resident who was reportedly hit by a GNA. Despite interviews with the resident, staff, and other residents, the facility did not obtain a statement from the alleged perpetrator, which was a critical oversight in the investigation process.
The facility failed to uphold resident dignity and staff identification protocols. A GNA entered a resident's room without knocking, and another GNA was observed without a visible name badge. Both staff members acknowledged the expectations and their lapses. These incidents were reported to the NHA and DON.
A facility failed to accurately code a resident's discharge status on the MDS assessment. The resident was discharged to another nursing home, but the MDS incorrectly recorded the discharge as to a short-term general hospital. This error was confirmed by the Social Worker Director, an LPN, and the Lead MDS Coordinator, who acknowledged the need for correction. The NHA was informed of the inaccuracy.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific health needs. A resident experienced unmanaged constipation, another had no care plan for IV hydration despite IBS-related diarrhea, and a third lacked a care plan for ADL support despite being dependent on staff. These oversights were confirmed by facility staff.
A resident with documented preferences for various activities was frequently observed sitting inactive in a hallway, indicating a failure by facility staff to provide a personalized and ongoing activities program. Despite the resident's care plan requiring participation in activities 3-5 times weekly, minimal engagement was documented, and staff interviews confirmed limited activity involvement.
A facility failed to schedule a neurology consultation for a resident with New Onset Seizure, despite hospital discharge instructions and progress notes from physicians and nurse practitioners indicating the need for follow-up. Staff interviews revealed a lack of clarity in the appointment scheduling process, and the Medical Director acknowledged the oversight, noting the resident's stability on medication.
A facility failed to adhere to its respiratory care protocols for a resident requiring oxygen therapy. The surveyor observed that the oxygen humidifier bottle and tubing were not dated, and there was no oxygen usage sign on the resident's door. The facility's policy required these measures, and the DON acknowledged the oversight.
A facility failed to discontinue a medication in a timely manner for a resident with cognitive and psychiatric diagnoses. Despite a pharmacist's recommendation and a physician's order to discontinue Oxycodone PRN due to non-use, the medication was not discontinued until two months later. The DON confirmed the oversight during an interview, highlighting a lapse in following the process for pharmacy recommendations.
A resident with severe malnutrition and encephalopathy reported a painful dental issue upon admission, but the facility failed to provide prompt dental care. An initial assessment identified a broken tooth, but it was later altered to indicate no issues, and the resident was not referred for dental services. The administrator acknowledged the oversight.
The facility failed to provide meals according to the dietary preferences and needs of three residents, leading to deficiencies in food service. A resident received incorrect breakfast trays missing items like biscuits and coffee, while another resident on a gluten-free diet received unsuitable food. A third resident experienced issues with incorrect meal trays, resulting in missed meals. The Dietary Manager cited understaffing as a reason for delayed updates to dietary preferences.
The facility failed to meet the dietary needs of two residents. One resident did not receive the prescribed low-fat, low-residue diet, and the facility could not verify the initial diet order. Another resident was not provided with a lunch meal on dialysis days, despite leaving the facility after breakfast and returning in the afternoon. The facility did not ensure the resident had a meal during dialysis, and the meal tray was left on the food delivery cart.
Resident Rights Violated by Unauthorized Medicaid Application Submission
Penalty
Summary
The facility failed to honor a resident's right to make his/her own decisions regarding personal and financial affairs, including the right to refuse services, by submitting a Medicaid application without the resident's knowledge or consent. During an interview, the resident and the resident's daughter reported that the resident had previously informed the social worker that he/she did not want to apply for Medicaid and intended to return home. Despite this expressed wish, the facility proceeded to submit a Medicaid application on the resident's behalf, and the resident stated not knowing how the facility could do that without his/her information and permission. The Administrator confirmed in an interview that a Medicaid application had been submitted for the resident and stated it was done to help him/her. The Business Office Manager reported she had been advised by the facility that it was acceptable to submit the Medicaid application on the resident's behalf. Review of the Medicaid application showed it was completed under the designation "applicant without representative who lacks capacity to appoint a representative." However, review of the medical record revealed the resident had a BIMS score of 14, indicating he/she was cognitively intact and capable of making his/her own decisions. These findings show the facility inaccurately represented the resident's decision-making capacity while submitting the application without consent.
Incorrect Medication Indications Not Verified for Antiepileptic Drugs
Penalty
Summary
Surveyors identified that pharmaceutical services failed to ensure accurate indications for medications prescribed and administered to a resident. Review of the resident’s March 2026 MAR showed physician orders for Depakote 250 mg twice daily for seizures and Lamotrigine 25 mg, four tablets once daily, for epilepsy. Further review of the resident’s medical record revealed no history or current diagnosis of seizures or epilepsy to support these indications. In an interview, a staff member confirmed that the resident did not have epilepsy or seizures and that there was nothing in the medical file indicating any history of these conditions, and was unable to explain how the facility or pharmacy verified that the indications listed for these medications were correct.
Medication Administration Errors With Acetaminophen and Oxycodone
Penalty
Summary
Surveyors identified a deficiency in medication administration for one resident when review of the medical record and MARs showed that acetaminophen was given in excess of the ordered maximum daily dose. The physician had ordered acetaminophen 500 mg, two tablets by mouth every 8 hours as needed for moderate pain, with a directive not to exceed 3 g in 24 hours, and a separate order for Tylenol Extra Strength 500 mg, two tablets by mouth three times a day for pain. Review of the March MAR showed that on two dates the resident received both the scheduled three-times-daily acetaminophen and additional PRN acetaminophen, totaling 4,000 mg in 24 hours, which exceeded the 3,000 mg limit specified in the order. During interview, facility staff reviewed the MAR with the surveyor and acknowledged that the resident received more than 3 g of acetaminophen on those dates. Further review of the same resident’s record showed physician orders for oxycodone 5 mg by mouth every 6 hours as needed for mild to moderate pain, and oxycodone 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10. The March MAR documented that on one date the resident received oxycodone 5 mg at 7:47 a.m. for pain level 5 and then oxycodone 7.5 mg at 9:37 a.m. for pain level 4, which was before the 6‑hour interval had elapsed. Additional MAR review showed that the resident received oxycodone 7.5 mg on multiple dates for pain levels of 3, 4, and 6, which did not meet the order requirement that this dose be used only for severe pain rated 7 to 10. In interviews, staff confirmed that the 7.5 mg oxycodone was administered both before the 6‑hour interval and for pain levels outside the ordered severity range, and that these administrations were in error.
Resident Lacked Access to Phone and Working TV Remote
Penalty
Summary
Surveyors identified a deficiency in which a resident did not have access to a personal or facility-provided phone and had a non-functioning TV remote control in their room. During review of an intake alleging multiple concerns, staff confirmed that there was only one phone jack in the semi-private room, and that the single phone line was connected to the roommate’s phone. The resident therefore did not have a phone of their own in the room. When asked how the resident communicated privately with family, a GNA and an RN stated that the resident sometimes used the roommate’s phone, and the RN confirmed that the resident did not have a personal or facility phone. Further observation in the resident’s room with the Administrator and Maintenance Director showed that there was only one phone jack available in the room, consistent with prior staff statements. During the same observation, the surveyor asked whether the resident’s TV remote control worked. The Maintenance Director attempted multiple times to turn on the TV using the remote and was unable to do so, ultimately turning the TV on manually. These observations confirmed that the resident lacked direct access to a working phone and a functioning TV remote control in their room.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the Minimum Data Set (MDS) assessments for 27 out of 33 residents reviewed during the annual survey. The MDS is a critical component for assessing the needs of residents in nursing homes, and timely submission is required to ensure proper care. The assessments were not completed and transmitted within the required 14-day period following the Assessment Reference Date (ARD) for various types of assessments, including annual, quarterly, and discharge assessments. The Lead MDS Coordinator acknowledged the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses responsible for completing the MDS assessments from three to two. The facility prioritized Medicare assessments over Medicaid and private ones, which contributed to the delay. The Nursing Home Administrator and the Director of Nursing were informed of the issue, highlighting the facility's awareness of the deficiency.
Facility Fails to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to ensure a safe environment by not maintaining acceptable hot water temperatures in resident bathroom sinks. During a recertification survey, surveyors observed that the hot water temperatures in several resident rooms exceeded the maximum allowable limit of 120 degrees Fahrenheit, with temperatures recorded as high as 128.2 degrees Fahrenheit. The Maintenance Director (MD) stated that weekly water temperature monitoring was conducted and documented in TELS, but no recent concerns had been noted. Despite the mixing valve being set at 118 degrees Fahrenheit, the observed temperatures were significantly higher. The MD was unable to explain the discrepancy between the mixing valve setting and the actual water temperatures. An observation of the water system showed the mixing valve temperature at 114 degrees Fahrenheit, yet the water temperatures in resident rooms remained elevated. The MD suggested that the temperature variations could be due to the continued use of water, but no definitive explanation was provided. This deficiency has the potential to affect all residents in the facility.
Failure to Ensure Homelike Environment and Accommodate Resident Needs
Penalty
Summary
The facility failed to provide a homelike environment and accommodate the needs of residents, as observed during a survey. Multiple environmental concerns were noted in resident rooms, including stained ceiling tiles, missing bathroom call bell pull cords, holes in walls, and a plastic bag covering a smoke detector. These issues were acknowledged by the Nursing Home Administrator during a tour of the facility. The lack of a homelike environment was evident for several residents, as these deficiencies were observed in multiple rooms. Additionally, a resident expressed discomfort due to an air mattress that was not ordered by a physician and caused difficulty sleeping. Despite informing the nursing staff about the discomfort, the issue was not addressed promptly, taking three days to resolve. The resident's discomfort and inability to sleep were communicated to the Unit Manager and the Assistant Director of Nursing, highlighting a failure to accommodate the resident's needs in a timely manner.
Failure to Complete MDS Assessments Timely Due to Staffing Issues
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required timeframe for six residents during the annual survey. The MDS assessments, which are crucial for ensuring residents receive appropriate care, were not completed within the 14-day period following the Assessment Reference Date (ARD) as mandated by CMS guidelines. Specifically, the assessments for five residents were more than 30 days overdue, and the initial comprehensive assessment for another resident was not completed within 14 days of admission. The Lead MDS Coordinator acknowledged the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses responsible for MDS assessments from three to two. The Nursing Home Administrator and the Director of Nursing were informed of these findings, which highlight the facility's inability to adhere to the required timelines for MDS assessments due to staffing issues.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments within the required timeframe for 18 out of 33 residents reviewed during the annual survey. The MDS is a core set of data elements that form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. According to CMS guidelines, an MDS Quarterly assessment must be completed within 14 days of the Assessment Reference Date (ARD). However, the review revealed that the assessments for the identified residents were still in progress and not completed within the specified timeframe. The Lead MDS Coordinator confirmed the delay in completing the assessments, attributing it to an increased number of facility admissions and a reduction in the number of nurses available to complete the MDS assessments, from three to two. Currently, only the Lead MDS Coordinator and an LPN are responsible for completing these assessments. The Nursing Home Administrator and the Director of Nursing were notified of this concern.
Deficiencies in Care Plan Meetings and Documentation
Penalty
Summary
The facility failed to provide invitations to residents for care plan meetings, did not conduct care plan meetings as required, and did not revise care plans for several residents. This deficiency was identified in five out of ten residents reviewed. For instance, Resident #1, who had moderate cognitive impairment, was not invited to care plan meetings, and there were no conference notes or invitations documented. The social worker responsible could not explain the lack of invitations, and the administrator acknowledged the deficient practice. Resident #62 reported not recalling recent care plan meetings, and the medical record review showed only one documented meeting in the past year. The Nursing Home Administrator confirmed the lack of additional documentation for care plan meetings for this resident. Similarly, Resident #58 stated they had never been invited to a care plan meeting, and the records showed only two documented meetings in the past year, with no invitation for the August 2024 meeting. Additionally, there was a discrepancy in Resident #58's care plan regarding dialysis access, which was not updated to reflect the current AV Fistula. Residents #158 and #164 also experienced deficiencies in care plan meetings. Resident #158 had only one documented care plan meeting since May 2022, and Resident #164 had only one documented meeting during their stay from December 2022 to January 2024. The social service designee confirmed that care plan meetings were not up to date, and the Nursing Home Administrator acknowledged the lack of documentation and the late status of care plan meetings for these residents.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, as evidenced by discrepancies in documentation and missing records. For instance, Resident #94's activity participation was not accurately documented in the electronic health record (PCC) for December 2024 and January 2025, and there was no evidence to support the resident's attendance in activities according to their care plan. Similarly, Resident #256's activity participation was not documented in PCC, and there was no evidence of the resident's newspaper reading activities or refusals to attend activities. Additionally, the facility did not ensure the accuracy of medication administration records. Resident #166 did not receive Atorvastatin Calcium for ten days, as confirmed by a review of the Medication Administration Record (MAR) and an interview with the Assistant Director of Nursing. Furthermore, Resident #455 was observed lying on a standard mattress instead of the ordered air mattress, despite the Task Administration Record (TAR) indicating that the air mattress was monitored and functioning correctly. The facility also failed to maintain accurate Medical Orders for Life-Sustaining Treatment (MOLST) forms. Resident #1, who had moderate cognitive impairment, was incorrectly marked as a cognitive intact consent party on the MOLST form. Similarly, Resident #10, with a history of cognitive impairment, had a MOLST order form that did not accurately reflect their cognitive status. These deficiencies highlight the facility's failure to ensure accurate documentation and adherence to professional standards in maintaining medical records and orders.
Neglect of Resident's ADL Care Leads to Distress
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by the case of a resident who did not receive necessary Activities of Daily Living (ADL) care during an entire shift. The resident was found with a soaked gown and bed linen, which caused significant distress. The complaint, submitted to the Office of Health Care Quality, highlighted that the resident's call light was on, and the resident expressed a need to be cleaned and have their wet bed linens changed. The night shift staff discovered the resident in this condition, indicating that the neglect occurred during the evening shift. A health status note from an LPN documented that the resident's diaper and bed had been wet throughout the evening shift, leading to bed soreness. The resident was in distress and screaming due to the lack of care. The LPN and an aide eventually attended to the resident's needs. During an interview, the Director of Nursing acknowledged awareness of the incident and mentioned providing in-service training to the LPN involved for proper documentation and reporting of patient concerns.
Failure to Obtain Statement from Alleged Perpetrator in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. A family member reported that the resident's Geriatric Nurse Assistant (GNA) allegedly hit the resident in the back of the head five times. The incident was reported approximately two weeks after it allegedly occurred. The resident, who had a BIMS score indicating moderate cognitive impairment, denied being hit when interviewed. Other staff and residents also denied knowledge or witnessing any abuse. Despite these interviews, the facility did not obtain a statement from the alleged perpetrator, which was a critical step missing in the investigation process. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were involved in the investigation. They followed several protocols, such as removing the alleged staff from the schedule, conducting a head-to-toe assessment of the resident, notifying the doctor and family, involving the Social Worker, and reporting the incident to law enforcement. However, the failure to obtain a statement from the alleged perpetrator was a significant oversight in the investigation, as acknowledged by the NHA when made aware of the deficiency.
Failure to Ensure Resident Dignity and Staff Identification
Penalty
Summary
The facility failed to ensure the dignity of its residents, as evidenced by two specific incidents involving nursing staff. In the first incident, a Geriatric Nursing Assistant (GNA) entered a resident's room without knocking, which was confirmed during an interview with the resident and the GNA. The GNA acknowledged the expectation to knock before entering and admitted to not doing so. In the second incident, another GNA was observed without a visible name badge while delivering food outside a resident's room. Upon inquiry, the GNA confirmed that all staff were expected to wear name tags, and she was later seen with a makeshift name tag made from tape. These actions were reported to the Nursing Home Administrator and the Director of Nursing at the time of the surveyor's exit.
Inaccurate MDS Discharge Coding
Penalty
Summary
The facility failed to accurately code a resident's discharge status on the Minimum Data Set (MDS) assessment. This deficiency was identified for one resident who was reviewed for hospitalizations during the survey. The resident was discharged to another nursing home, as indicated in the discharge summary dated October 8, 2024. However, the MDS Discharge Return Not Anticipated assessment incorrectly recorded the discharge status as a short-term general hospital (acute hospital). This discrepancy was confirmed through interviews with the Social Worker Director, a Licensed Practical Nurse, and the Lead MDS Coordinator, who acknowledged the error and indicated that the assessment should reflect the discharge to another facility. The Nursing Home Administrator was informed of the MDS inaccuracy.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific health needs. Resident #355 experienced constipation from late December 2024, but no bowel regimen was initiated until January 2025. Despite receiving various medications for constipation starting January 2, 2025, there was no evidence of a care plan to address this issue. The resident reported that the medication led to diarrhea and vomiting, indicating a lack of effective management and planning for the resident's condition. Resident #356, diagnosed with irritable bowel syndrome (IBS), experienced non-stop diarrhea and was seen by a Nurse Practitioner on January 8, 2025, for nausea, vomiting, and diarrhea. The NP ordered IV hydration and other treatments, but there was no care plan developed for the use of IV fluids for hydration. The Unit Manager and Assistant Director of Nursing confirmed the absence of a care plan for this resident's hydration needs, highlighting a gap in the facility's care planning process. Resident #12, who was dependent on staff for activities of daily living (ADLs) due to conditions such as schizophrenia, muscle weakness, and intellectual disabilities, did not have a care plan addressing their dependence on staff for personal hygiene, bathing, dressing, and toileting. Despite being aware of the resident's needs, the staff failed to initiate and implement a care plan to ensure adequate support for ADLs. This oversight was acknowledged by the Director of Nursing, who was informed of the findings.
Failure to Provide Individualized Activities Program
Penalty
Summary
The facility staff failed to provide an ongoing activities program tailored to meet the needs and preferences of a resident, identified as Resident #94. Observations made during the survey revealed that the resident was frequently found sitting in a wheelchair in the hallway across from the nurses' station, not participating in any activities. The resident's Minimum Data Set (MDS) assessment indicated a strong preference for activities such as reading, listening to music, keeping up with the news, participating in group activities, and engaging in religious services. Despite these documented preferences, the resident's activity care plan, which required participation in activities of choice 3-5 times weekly, was not effectively implemented. Interviews with facility staff, including the Assistant Director of Nursing and the Activities Director, confirmed that while the resident was sometimes taken to group activities, they often did not stay long due to yelling out. The Activities Director acknowledged familiarity with the resident's preferences and health conditions but admitted to having limited documentation of the resident's participation in activities. A review of the resident's activity participation records showed minimal engagement, with only two days of documented activities in November 2024 and no records for December 2024 and January 2025. This lack of documentation and observed inactivity indicates a failure to provide a personalized and consistent activities program for the resident.
Failure to Schedule Neurology Consultation for Resident
Penalty
Summary
The facility failed to follow up on a recommendation for a neurology consultation for a resident who was readmitted with a primary diagnosis of New Onset Seizure. The resident's discharge summary from the hospital requested an appointment with a Neurologist within four weeks of discharge. Despite multiple progress notes from physicians and nurse practitioners indicating the need for a follow-up with neurology, there was no documentation in the resident's clinical record to confirm that an appointment was scheduled or attended. Interviews with facility staff revealed a lack of clarity and follow-through in the process of scheduling the necessary consultation. Staff members, including the Nurse Manager, Nurse Supervisor, or Charge Nurse, were responsible for making appointments based on physician orders and hospital recommendations. However, they were unable to confirm whether the neurology appointment was scheduled. The Medical Director acknowledged the oversight and noted that the resident was stable on medication, suggesting that a consultation was not deemed necessary after two months.
Failure to Follow Respiratory Care Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident, as observed during a survey. The surveyor noted that the oxygen humidifier bottle and tubing attached to the oxygen concentrator in the resident's room were not dated, and there was no oxygen usage sign on the resident's room door or doorframe. The resident had physician orders for oxygen therapy and a care plan related to respiratory illness, which included changing the oxygen tubing and humidifier bottle weekly on the night shift. The facility's policy required an oxygen sign on the resident's door and specified that the tubing and humidifier bottle should be changed weekly and every seventy-two hours, respectively. During an interview, the Director of Nursing acknowledged that the expected procedures for oxygen signage and equipment changes were not followed for this resident, indicating an oversight in adhering to the facility's policy.
Failure to Timely Discontinue Medication as Ordered
Penalty
Summary
The facility failed to discontinue a medication in a timely manner as ordered by the attending physician for a resident with diagnoses including Cognitive Communication Deficit, Major Depressive Disorder, and Psychosis. The resident was admitted to the facility, and on September 11, 2024, the Licensed Pharmacist recommended discontinuing Oxycodone PRN as it was not utilized by the resident. The physician reviewed this recommendation and ordered the discontinuation of the medication on September 17, 2024. However, the facility did not follow up on this order, and the medication was not discontinued until November 15, 2024, after a second recommendation from the pharmacist on November 12, 2024. The Director of Nursing confirmed the findings during an interview, explaining the process for handling pharmacy recommendations and the failure to implement the physician's order.
Failure to Provide Prompt Dental Care
Penalty
Summary
The facility staff failed to promptly provide or obtain dental services for a resident, leading to a deficiency. During a floor rounding, the resident reported a dental issue involving a cap that had fallen out, causing pain. The resident had informed the staff about this issue upon admission. A review of the resident's records revealed that an initial dental assessment was conducted by a social worker, identifying a broken or loose-fitting tooth. However, the assessment was later altered to indicate no dental issues, and the resident was not referred to the on-site dental service. The resident was admitted with severe protein-calorie malnutrition and encephalopathy, which could have been exacerbated by the dental issue. Despite the initial identification of a dental problem, the facility did not ensure the resident received the necessary dental care. The administrator acknowledged the failure to provide or schedule a dental visit, confirming the deficiency in the facility's response to the resident's dental needs.
Deficiencies in Meal Service and Dietary Adherence
Penalty
Summary
The facility failed to provide meals that adhered to the dietary preferences and needs of three residents, leading to deficiencies in food service. Resident #455 received breakfast trays that did not match the meal tickets, missing items such as biscuits, gravy, coffee, and milk. The resident expressed concerns about inadequate food supplies, as syrup was provided instead of butter and jelly. The Nursing Home Administrator confirmed that the kitchen did not prepare the menu items as indicated, such as French toast. Resident #255, who follows a gluten-free diet, repeatedly received meals that did not align with this dietary restriction. The resident's meal tray included items like muffins and sausage patties that were not suitable for a gluten-free diet. The Dietary Manager acknowledged the oversight and attributed it to being understaffed, which delayed the updating of the resident's dietary preferences. Resident #357 experienced issues with receiving incorrect meal trays, resulting in missed meals. The resident reported that the staff removed incorrect trays but did not replace them, leading to missed breakfasts. The Registered Dietitian and Certified Dietary Manager were aware of the resident's specific preferences, but these were not documented in the electronic charting system, contributing to the discrepancies in meal service.
Failure to Meet Dietary Needs and Provide Meals for Dialysis
Penalty
Summary
The facility failed to ensure that a resident's dietary needs were met and did not provide a lunch meal for a resident attending outpatient dialysis. For Resident #169, the facility did not adhere to the prescribed low-fat, low-residue diet as required by the resident's medical condition. The hospital discharge summary indicated a need for a low fiber, low insoluble residue diet, avoiding coffee and dairy. However, the resident was placed on a regular diet with mechanical soft texture upon admission. The Registered Dietician and Dietary Manager were unable to verify the initial diet order sent to the kitchen due to the absence of a copy of the diet card. The Dietary Manager noted that the resident's family had expressed dissatisfaction with the diet provided and had requested a low-fat diet, but there was no documentation of when these changes were made. For Resident #58, the facility did not provide a lunch meal to accompany the resident on scheduled dialysis days, despite the resident leaving the facility after breakfast and returning around 4:00 PM. The resident reported not receiving lunch at the dialysis center, and the meal tray was observed left on the food delivery cart. The assigned RN confirmed that the facility did not provide a lunch for the resident on dialysis days. The Nursing Home Administrator and Director of Nursing were informed of the issue, but no additional information was provided regarding the provision of lunch for the resident.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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