Chestertown Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Chestertown, Maryland.
- Location
- 415 Morgnec Road, Chestertown, Maryland 21620
- CMS Provider Number
- 215260
- Inspections on file
- 19
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 50
Citation history
Health deficiencies cited at Chestertown Nursing And Rehab during CMS and state inspections, most recent first.
The facility did not ensure a homelike dining environment by keeping the dining room locked during breakfast and dinner, resulting in residents having their meals delivered to their rooms instead of dining communally. The NHA confirmed this practice was due to residents not being ready in the morning and the dining room only being opened for lunch.
Facility staff did not maintain sufficient weekend nursing staff coverage, as shown by PBJ data indicating multiple weekends with staffing below the facility's established HPPD goal. The Staffing Coordinator confirmed the low staffing levels and acknowledged that agency staff had not been used for support during this period. The deficiency was identified through review of staffing records and interviews, and leadership was notified of the findings.
Surveyors identified unsanitary conditions in the kitchen, including uncovered seasonings, dirty sinks, and food stains on surfaces. Additionally, multiple food items in the walk-in refrigerator were found without required labels or dates, and staff could not confirm when these items were prepared or stored.
A resident was subjected to rough and aggressive handling by a GNA, resulting in bruising on the ankle. The incident was identified after another staff member observed the injury and the resident reported the abuse. The facility's investigation confirmed the allegation based on collected statements and physical evidence.
A GNA observed bruising on a resident's ankle and, after the resident reported rough treatment by staff, the facility did not report the suspected abuse to authorities within the required two-hour window. The delay in reporting was confirmed by the administrator during the survey.
Facility staff did not conduct a thorough investigation or maintain proper documentation after a resident reported inappropriate comments by a staff member during medication administration. The facility's conclusion relied solely on a nurse practitioner's note, despite no documented behavioral history to support the assessment, and failed to provide evidence of follow-up evaluations or social work involvement as claimed.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and missing details necessary for comprehensive care.
A resident's care plan was not updated after an increase in Seroquel dosage and following a behavioral incident involving agitation and wandering into other residents' rooms. Despite documentation of these changes and staff acknowledgment that the care plan should have been revised, no updates were made to address the resident's altered condition and behaviors.
A resident with a colostomy did not have a physician order or care plan for colostomy care, and documentation of colostomy bag changes was inconsistent, with no records for several weeks prior to discharge. Facility leadership confirmed that proper orders and daily documentation were expected but not present, resulting in a deficiency in colostomy care.
Staff failed to knock before entering a resident's room on two observed occasions, despite facility expectations to do so, resulting in a failure to honor resident rights to privacy and dignity.
A resident's required Advanced Beneficiary Notice of Noncoverage (ABN) was not provided or documented when Medicare Part A services ended. The business office manager could not find evidence of the ABN or documentation of any contact with the resident's representative, and the DON confirmed that such documentation should have been present.
Two residents were administered additional or continued psychotropic medications without documented attempts at non-pharmacological interventions or timely response to pharmacy recommendations for gradual dose reduction. Staff and medical director interviews confirmed the lack of documentation and intervention prior to medication changes.
Facility staff did not complete the required electronic transfer form and bed hold notice in the EMR for a resident's hospital transfer. While these forms were completed for a previous transfer, the responsible nurse failed to document them for a subsequent transfer, as confirmed by the DON and Regional Policy Nurse.
A resident's MDS assessment failed to accurately document two pressure ulcers as present on admission, despite medical records indicating their existence prior to entry. The error was identified during a survey and confirmed by the MDS Coordinator.
Facility staff did not provide evidence that a Level 1 PASARR was completed prior to or at the time of admission for a resident with paranoid schizophrenia, as required for individuals with mental disorders or intellectual disabilities. Documentation of the required screening was not available during the survey, and only a later PASARR was produced.
Staff did not consistently obtain or document blood pressure readings prior to administering Metoprolol to a resident, as required by physician's orders. The medication was given throughout the month despite limited documentation of blood pressure checks, and interviews with an LPN and the DON confirmed that readings were likely not performed when not recorded.
A resident's decreased hearing was evaluated by an audiologist, who recommended Debrox for impacted cerumen. Facility staff did not obtain a physician order for Debrox or document a reason for not following the recommendation, resulting in a failure to address the resident's hearing concerns.
A resident dependent on staff for ADLs did not consistently receive scheduled showers, with staff substituting bed baths and inconsistently documenting care and refusals. Review of records showed gaps in shower provision and lack of proper documentation explaining missed showers or refusals.
Staff failed to monitor and assess urinary output for a resident with a Foley catheter, resulting in missed signs of infection and delayed physician notification, while another resident with liver cell carcinoma did not receive pain assessments or PRN morphine as ordered. Documentation was incomplete or missing for both urinary monitoring and pain management, and staff interviews confirmed lapses in following physician orders.
A resident who was unable to reposition independently developed two new pressure ulcers after staff failed to consistently turn and reposition the resident as required by facility protocol. Despite having a low air loss mattress and orders for frequent turning, documentation revealed multiple missed repositioning intervals, and staff interviews confirmed that both interventions were necessary to prevent new wounds.
Staff failed to label and date oxygen delivery equipment and did not adhere to the prescribed oxygen flow rate for a resident on oxygen therapy. An LPN was unable to confirm when the equipment was last changed, and the oxygen was being administered at a higher rate than ordered, without clinical justification. The DON confirmed that equipment should be labeled and dated after changes and that oxygen flow rates must match physician orders.
Two residents did not receive appropriate pain management as required by their care plans and physician orders. One resident's chronic pain complaints were not addressed by staff, and another resident with cancer did not receive regular pain assessments or PRN morphine as ordered. Staff failed to document pain assessments and did not administer pain medication when needed, as acknowledged by the DON.
A resident who experienced ongoing back pain was readmitted after hospitalization, but the attending physician did not address the hospital's recommendation for a transdermal fentanyl patch in the follow-up note. Both the attending physician and medical director confirmed that the discharge summary and its recommendations were not reviewed or incorporated into the resident's care plan as required.
Surveyors found that annual performance reviews for five GNAs were not conducted or documented, as confirmed by both the ADON and HR. The facility's process relied on verbal reminders to supervisors, with no evidence of completed reviews in the employee files.
Staff did not post the actual hours worked per shift for RN, LPN, CMA, and GNA on two units. Observations showed that while staff names and assignments were listed, the required hours worked section was left blank. Interviews indicated that the unit manager was unaware of the requirement to post actual hours worked.
Surveyors identified that narcotic record books were not consistently signed by both incoming and outgoing nurses, as required by protocol. Multiple missing signatures were found across several units and shifts, and staff confirmed the expectation for dual signatures at each shift change. Review of personnel files showed repeated corrective actions for similar failures by a nurse, and the DON acknowledged the ongoing issue.
The facility did not ensure that MRR recommendations from the consulting pharmacist were addressed by providers for multiple residents. In several cases, recommendations for gradual dose reduction of psychotropic medications were not acted upon, and increases in medication dosages were made without documented rationale or response to the pharmacist's input. Documentation of provider decisions and non-pharmacological interventions was also lacking.
A resident with cognitive impairment and multiple diagnoses was not re-evaluated by psychiatry after a pharmacy recommended gradual dose reduction (GDR) of psychotropic medications. The Medical Director increased the resident's Seroquel dosage without documenting the rationale, discussion of the GDR recommendation, or use of non-pharmacological interventions, and staff confirmed that no such interventions or documentation were provided.
Surveyors found that opened bottles of house stock medications, such as Melatonin, Vitamin B12, Magnesium Oxide, Guaifenesin, Aspirin, and Bisacodyl, were not dated as required on two medication carts. Additionally, a medication room refrigerator log showed missing temperature checks and documentation for several days and shifts, despite facility expectations for twice-daily monitoring. These deficiencies were confirmed through staff interviews and review of temperature logs.
A resident with worn down dentures experienced ongoing difficulty chewing and sore gums, repeatedly reporting these issues to staff. Although the RD documented the concerns and notified the kitchen, SLP, and activities personnel, no timely dental referral was made. The SLP recommended a pureed diet, but the SW was not informed of the dental issues until months later, and the DON acknowledged delayed interventions.
Staff failed to ensure complete and accurate PASARR documentation for three residents, with missing or incomplete sections and absent follow-up records for required screenings. Additionally, a resident's medical record lacked skin and wound documentation after discharge to a hospital, and the facility could not provide information about the receiving hospital. These deficiencies reflect failures in maintaining required medical records.
Surveyors observed that dirty linen was stored in bins in one room while clean, uncovered linen was kept on tables in an adjacent room, with the door between the two rooms left open. The Director of Housekeeping stated that the door had always been kept open and was unaware this was an infection control issue. The DON was informed of the concern.
Surveyors identified that two residents did not have proper documentation for pneumococcal and influenza vaccinations. One resident lacked records for both vaccines, while another was missing documentation for the pneumococcal vaccine. The DON confirmed the facility did not have an adequate process for tracking immunization records.
Two residents were not screened for or offered the COVID-19 vaccine, and there was no documentation of this process in their records. The DON confirmed the facility lacked an effective process for immunization screening and documentation.
Surveyors observed multiple environmental deficiencies, including a damaged closet door with an exposed latch, cracked floor tiles in a soiled utility room, a shower stall with a dark substance between tiles, and several room doors with cracked or missing coating. These issues compromised the safety and comfort of residents, staff, and the public.
Surveyors observed multiple flies in food service and resident care areas, including in a resident's room and the kitchen, with staff attributing the issue to an open kitchen door near the refuse area. Despite biweekly pest control visits and the use of fly traps, flies were present around food carts and in hallways, and staff relied on reports from others to identify pest problems.
Surveyors found that required annual QAPI training was not documented for several staff members, including GNAs, an LPN, and an RN. Despite claims of ongoing training and an annual skills fair, the facility could not provide evidence that these staff completed the mandated QAPI education.
Surveyors found that required infection prevention and control training was not documented for multiple staff members, including GNAs, an LPN, and an RN. Despite claims of ongoing training and an annual skills fair, no records were available to verify completion of the mandatory education.
Surveyors found that documentation of compliance and ethics training was missing from the files of all sampled staff, including GNAs, an LPN, and an RN. Despite claims of ongoing training and an annual skills fair, no records could be produced to verify that required compliance and ethics education had been completed for the current year.
Surveyors found that required annual in-service training documentation was missing for five GNAs. Despite ongoing training sessions and a skills fair, the facility could not provide evidence that the annual in-service training had been completed for these staff members, as confirmed by a review of employee files and additional records provided by the ADON.
Surveyors found that documentation of dementia training was missing from the files of all reviewed staff, including GNAs, an LPN, and an RN. Despite claims of ongoing education and an annual skills fair, no records could be produced to verify that required dementia training had been completed.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide residents with a homelike dining environment as required. During the annual survey, it was observed that the dining room on the Chesapeake unit was locked and not used for breakfast, with residents instead receiving their breakfast meals delivered to their rooms. An interview with the Nursing Home Administrator confirmed that the dining room remained locked for both breakfast and dinner, only being opened for lunch. The administrator explained that the dining room was kept locked in the morning because residents were not up and ready by breakfast time, and it was locked again for dinner.
Failure to Maintain Adequate Weekend Nursing Staff Levels
Penalty
Summary
Facility staff failed to ensure sufficient weekend nursing staff coverage, as evidenced by a review of the Payroll-Based Journal (PBJ) report and facility assessment. The PBJ report for the second quarter of 2025 flagged the facility for excessively low weekend staffing levels. The facility's own staffing goal was set at 3.15 Hours Per Patient per Day (HPPD), but data from March, April, and May 2025 showed that this standard was not met on multiple weekends. Specifically, the HPPD fell below the facility's goal on 4 out of 5 weekends in March, all weekends in April, and 2 out of 5 weekends in May. During an interview, the Staffing Coordinator acknowledged the low weekend staffing and confirmed that the facility had not used agency staff since April 2024. The deficiency was further substantiated by the facility assessment, which was updated in 2025 and outlined the need for adequate staffing to provide continuity of care. The Administrator and Director of Nursing were made aware of the PBJ report findings during the survey entrance conference.
Unsanitary Kitchen Conditions and Improper Food Labeling
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen operations during a recertification survey. Five open jars of seasonings were found uncovered on a shelf, with seasoning particles scattered around. The food preparation sink had visible white oily stains, and the three-compartment sink showed white lime deposits on the faucets. Three handwashing sinks in the kitchen were dirty with brown stains. Additionally, dried and wet food stains were present on the kitchen walls, counters, and tables. These unsanitary conditions were confirmed by facility staff during the survey. Further inspection of the walk-in refrigerator revealed several food items, including bowls of lettuce, cheese, raw ham, desserts, and bread rolls, that were not labeled or dated. When questioned, the Assistant Food Service Director was unable to provide information on when these items were prepared or stored, acknowledging that all food items should have been labeled and dated. The dietary aide confirmed that the desserts were from a previous meal and that the staff responsible had not labeled them, making it unclear when the items were made or when the raw ham was moved from the freezer.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
A deficiency occurred when a geriatric nursing assistant (GNA) was observed to have been rough and aggressive with a resident, resulting in bruising on the resident's right ankle. The incident was initially identified when another staff member noticed the bruising and questioned the resident, who then reported the aggressive behavior by the GNA. The facility conducted an investigation, which included reviewing statements and physical findings, and verified the allegation of abuse. The Nursing Home Administrator was aware of the verified abuse incident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse within the required two-hour timeframe. On 4/20/25 at 11:30 AM, a Geriatric Nursing Assistant observed bruises on a resident's right ankle and, upon inquiry, the resident stated that a GNA had been rough and aggressive with them the previous day. Although this information was documented, the facility did not report the incident to the Office of Health Care Quality until 1:10 PM, exceeding the mandated reporting window. The Nursing Home Administrator acknowledged that the incident was not reported within the required timeframe during the surveyor's review.
Failure to Thoroughly Investigate and Document Abuse Allegation
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of staff-to-resident abuse and did not maintain adequate documentation. A resident reported to a nurse supervisor that a staff member made inappropriate comments during medication administration, which made the resident feel uncomfortable and embarrassed. The facility's initial response included contacting the police, suspending the alleged perpetrator, and arranging for a psychiatric nurse practitioner and social worker to meet with the resident. Statements were collected from involved parties. However, the facility's follow-up investigation relied solely on a nurse practitioner's progress note, which attributed the resident's report to attention-seeking behavior and fantasies, despite no documented history of such behaviors in the resident's medical or psychiatric records. The facility was unable to provide documentation supporting its conclusion that the incident could not be substantiated, including evidence of behavioral concerns, records of a psychological evaluation related to the incident, or verification that the social worker met with the resident as claimed. The administrator acknowledged that the decision not to substantiate the incident was based only on the nurse practitioner's note and that resident records were not reviewed. The lack of thorough investigation and supporting documentation led to the cited deficiency.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or include clear, measurable goals and interventions.
Failure to Revise Care Plan After Medication Change and Behavioral Incident
Penalty
Summary
The facility failed to revise a resident's care plan following significant changes in the resident's medication regimen and after a facility-reported incident. Specifically, a resident was prescribed an additional dose of Seroquel (Quetiapine Fumarate) by the Medical Director, but the care plan was not updated to reflect this medication change. Progress notes indicated that the resident exhibited agitation and aggression, and although the DON stated that the care plan should have been updated with new goals and interventions, the care plan remained unchanged at the time of review. Additionally, after an altercation between two residents, both diagnosed with dementia, the care plan for the involved resident was not revised to address new behavioral concerns. Documentation and staff statements confirmed that the resident frequently became agitated and wandered into other residents' rooms, yet there was no care plan in place to address these behaviors. The Unit Manager and DON both acknowledged that the care plan should have included interventions for agitation and wandering following the incident, but no such updates were made.
Failure to Provide and Document Colostomy Care
Penalty
Summary
The facility failed to provide and document appropriate colostomy care for a resident who had a colostomy. The resident, who was cognitively intact and admitted for wound care and rehabilitation, had a history of a laparoscopic diverting sigmoid colostomy and sacral debridement. Despite the presence of other medical orders, there was no physician order for colostomy care or documentation specifying the frequency and interventions for colostomy management. Review of the resident's medical records showed sporadic documentation of colostomy bag changes, with the last entry occurring nearly a month before the resident's discharge, and no records of colostomy care during the final weeks of the resident's stay. Interviews with facility leadership confirmed that the expectation was for colostomy care to be provided, monitored, and documented according to physician orders, which should have included details such as site monitoring, output, and bag change frequency. Both the ADON and DON acknowledged that there should have been a physician order and a care plan for colostomy care, and that daily documentation was expected while the resident was under skilled services. The lack of a physician order, care plan, and consistent documentation led to the identified deficiency in colostomy care for the resident.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to maintain resident rights by not ensuring staff knocked before entering residents' rooms. During two separate observations on the Chesapeake unit, a registered nurse entered a resident's room without knocking, both during an interview with the resident and again shortly after, as witnessed by the surveyor. The Director of Nursing confirmed that the facility's expectation is for staff to knock prior to entering any resident's room. These incidents demonstrate that staff did not follow established protocols to respect residents' privacy and dignity.
Failure to Provide and Document Advanced Beneficiary Notice of Noncoverage
Penalty
Summary
The facility failed to provide the required Advanced Beneficiary Notice of Noncoverage (ABN) to a resident or their representative prior to the end of Medicare Part A coverage. Documentation reviewed for one resident showed that the last day of covered services was recorded, but there was no evidence that the ABN was given. The Business Office Manager was unable to locate any documentation of the ABN and stated that, since the resident was unable to sign, the representative would have been contacted by phone or mail. However, the Business Office Manager was unaware of the process for documenting such contact, and there was no record of a phone call or letter being sent. The Director of Nursing confirmed that documentation should exist if a phone call or letter was made or sent to the representative.
Failure to Attempt and Document Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that less restrictive alternatives were attempted and documented prior to administering additional antipsychotic medication for two residents reviewed for unnecessary medications. In one case, a medical director ordered an increased dose of Seroquel for a resident exhibiting agitation and aggression, but there was no documentation of non-pharmacological interventions being attempted before the medication increase. The medical record and staff interviews confirmed that no such interventions were provided or documented, and the medical director acknowledged the omission of both rationale and non-pharmacological orders. In another case, monthly pharmacy reviews identified irregularities in the medication regimen of a resident prescribed Seroquel, Lexapro, and Haldol. The pharmacist recommended evaluating the eligibility for gradual dose reduction (GDR) and monitoring for symptoms, but the recommended adjustments to the medications were not addressed for several months. The DON confirmed that while pharmacy reviews and recommendations were made, there was no documentation to show that non-pharmacological interventions were provided to the resident during this period.
Failure to Complete Required Transfer Forms and Bed Hold Notices
Penalty
Summary
Facility staff failed to ensure that required electronic transfer forms and bed hold notices were completed in the electronic medical record system (Point Click Care) for a resident who was transferred to the hospital. During a review of the resident's medical record, it was found that while an electronic transfer form and bed hold notice were completed for one hospital transfer, there was no documentation of these forms for a subsequent transfer. The surveyor requested proof of the required documentation for the second transfer, but none was provided. Interviews with the DON and Regional Policy Nurse confirmed that the nurse responsible for the resident's care during the second hospital transfer did not complete the electronic interact transfer form or the bed hold notice as required. The DON explained that the process is typically completed at the time of transfer and is the responsibility of the nurse sending the resident to the hospital, regardless of the day or time the transfer occurs.
Inaccurate MDS Assessment of Pressure Ulcers on Admission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status regarding pressure ulcers and wounds. Specifically, a review of one resident's medical record showed that a skin check documented four wounds, with two of them (on the left hip and right heel) noted as present on admission. However, the corresponding MDS assessment did not indicate that these two wounds were present on admission, instead marking all four wounds as not present on admission. This discrepancy was identified during a surveyor's review of the records, and the error was acknowledged by the Regional MDS Coordinator, who confirmed that the MDS should have reflected the wounds as present upon admission.
Failure to Complete PASARR Prior to Admission for Resident with Mental Disability
Penalty
Summary
Facility staff failed to provide evidence that a Level 1 preadmission screening and resident review (PASARR) was completed prior to or at the time of admission for a resident with a mental disability. The requirement is that all applicants to Medicaid-certified nursing facilities be screened for possible serious mental disorders, intellectual disabilities, and related conditions before admission. In this case, a resident admitted with a diagnosis of paranoid schizophrenia did not have documentation of a completed PASARR at the time of admission. During the survey, a review of the resident's paper and electronic medical records did not show a PASARR completed prior to or at the time of admission. When requested, the social worker was unable to provide the PASARR from the time of admission and only produced a PASARR dated nearly two years after the resident's admission. The deficiency was identified during the annual survey for one of two residents reviewed for PASARR compliance.
Failure to Follow Physician's Orders for Blood Pressure Medication Administration
Penalty
Summary
Facility staff failed to follow physician's orders and professional standards of quality when administering blood pressure medication to Resident #9. The physician's order required Metoprolol 25 mg to be given twice daily with instructions to hold the medication if the systolic blood pressure was less than 100 mmHg. Despite this, the medication was administered twice daily throughout July 2025, while blood pressure readings were only documented on four occasions during the month. Interviews with an LPN revealed that blood pressure should be checked prior to administration when parameters are ordered, and the DON confirmed that undocumented readings were likely not performed. This indicates that the required blood pressure monitoring prior to medication administration was not consistently completed or documented as ordered.
Failure to Follow Audiologist Recommendation for Earwax Removal
Penalty
Summary
Facility staff failed to provide appropriate treatment to maintain a resident's ability to perform activities of daily living, specifically regarding vision and hearing concerns. A resident reported that their concerns about vision and hearing were not addressed by the facility. Medical records showed that the resident was referred for an ear exam due to decreased hearing, and the audiologist found impacted cerumen and recommended Debrox for earwax removal. However, there was no physician order for Debrox or documentation explaining why the recommendation was not followed. The Assistant Director of Nursing confirmed that the staff responsible did not place the order for Debrox as recommended by the audiologist.
Failure to Provide Scheduled Showers and Accurate Documentation for Dependent Resident
Penalty
Summary
Facility staff failed to provide appropriate assistance with activities of daily living (ADLs) for a resident who was dependent on staff for showers. The resident reported that scheduled showers were not provided as expected on Wednesdays and Saturdays during the evening shift, and instead, staff offered bed baths. The resident also stated that staff sometimes documented refusals for showers that did not occur, indicating a discrepancy between the resident's account and staff documentation. A review of the facility's shower log and electronic medical records revealed inconsistent documentation of shower provision, with only a few dates recorded for showers over several months. There was no documentation explaining why the resident did not receive showers on other scheduled days, nor was there evidence of documented refusals. The Assistant Director of Nursing confirmed that staff were expected to provide showers and document any refusals, but this was not consistently done for the resident in question.
Failure to Monitor Urinary Output and Manage Pain per Physician Orders
Penalty
Summary
Staff failed to adequately monitor and assess urinary output and did not ensure pain was assessed and managed according to physician orders for two residents. For one resident with a Foley catheter, there were repeated instances of dark, bloody, and cloudy urine with clots, and staff did not irrigate the catheter tubing as needed. The resident was hospitalized twice, first for a urinary tract infection and later for sepsis, acute kidney injury, and diabetic ketoacidosis. Medical record reviews showed a lack of documentation regarding urinary monitoring, assessment, and timely notification to the physician about catheter blockage and changes in urine. A urinalysis ordered by the nurse practitioner was not collected, and staff interviews revealed inconsistent assessment and monitoring of urinary output. Another resident with liver cell carcinoma had a physician's order for pain evaluation every shift and PRN morphine for comfort care. Documentation showed that pain assessments were not consistently completed as ordered, with a gap of several days without any pain assessment recorded. Morphine was administered only sporadically, and there was no documentation explaining the lack of pain assessments or administration of PRN medication during the specified period. Staff interviews confirmed that pain assessments and documentation were not performed as required by the physician's orders. These deficiencies were identified through interviews, observations, and record reviews, and were acknowledged by facility staff, including the DON and unit manager. The lack of proper monitoring, assessment, and documentation directly contributed to the residents' unmet care needs and hospitalizations.
Failure to Consistently Reposition Dependent Resident Leads to New Pressure Ulcers
Penalty
Summary
A resident who was unable to reposition independently and was dependent on staff for turning and repositioning developed two new pressure ulcers while in the facility. The resident reported that staff did not consistently turn him/her every two hours as required. Medical record review confirmed that the resident had two wounds upon admission and was under the care of a Wound Nurse Practitioner, with preventative measures including turning/repositioning and use of a low air loss mattress. Despite these interventions, documentation showed multiple instances where the resident was not turned or repositioned according to protocol over several dates and time periods. The facility's own policy required that residents unable to reposition themselves be turned every hour. Interviews with staff confirmed that both turning/repositioning and the use of a low air loss mattress were necessary and that one did not replace the need for the other. Documentation and interviews indicated that staff failed to consistently implement these preventative measures, resulting in the development of new pressure ulcers for the resident.
Failure to Label Respiratory Equipment and Follow Oxygen Orders
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care to a resident receiving oxygen therapy. During observation, it was found that the oxygen tubing, nasal cannula, and humidifier bottle in use for the resident were not labeled or dated as required. The LPN present was unable to state when the equipment was last changed and acknowledged that it should be changed weekly and labeled accordingly. The Director of Nursing confirmed that the facility's expectation is for equipment to be labeled and dated immediately after being changed, with changes occurring weekly. Additionally, the staff did not follow the physician's order for oxygen administration. The resident was observed receiving oxygen at approximately 2.25 liters per minute, while the active physician order specified 2 liters per minute to maintain oxygen saturation above 92%, with titration up to 6 liters per minute only as needed. The LPN confirmed there was no clinical indication for the increased flow rate and subsequently adjusted it to the prescribed amount. The most recent oxygen saturation documented for the resident was 99%.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents by not following professional standards of practice and the residents' person-centered care plans. One resident consistently reported chronic back pain due to arthritis, which was documented by a nurse practitioner, but there was no evidence that the pain was addressed or that the care plan goal of being free from discomfort was met. The resident's medical record confirmed an active diagnosis of pain, yet the pain management regimen was not adjusted in response to the resident's ongoing complaints until after surveyor intervention. Another resident with multiple medical diagnoses, including liver cell carcinoma, was admitted with frequent, moderate pain that affected sleep and was not relieved by non-pharmacologic interventions. Despite physician orders for pain assessments every shift and PRN morphine for comfort care, pain assessments were not consistently documented, and PRN medication was not administered as ordered. Staff failed to document ongoing pain assessments and did not provide pain medication as directed, even when the resident was observed to be uncomfortable and agitated. The Director of Nursing acknowledged these findings during the survey.
Physician Failed to Address Hospital Discharge Recommendations After Resident Readmission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician reviewed a resident's total plan of care at each required visit. Specifically, after a resident was hospitalized and subsequently readmitted, the attending physician documented a follow-up note acknowledging the recent hospital stay but did not address the hospital's recommendation for a transdermal fentanyl patch to manage the resident's ongoing back pain. The discharge summary from the hospital, which included this recommendation, was present in the resident's medical record but was not acted upon by the physician during the first post-readmission visit. Interviews with both the attending physician and the medical director confirmed that the expectation was for physicians to review the entire plan of care, including discharge summaries and any recommendations or medication changes, upon a resident's readmission. Both acknowledged that the fentanyl patch recommendation was missed and not incorporated into the resident's care plan, and the facility did not identify this oversight until it was brought to their attention during the survey.
Failure to Conduct and Document Annual Nursing Aide Performance Reviews
Penalty
Summary
Facility staff failed to conduct annual performance reviews for nursing aides, as evidenced by the absence of such documentation in the employee files of five geriatric nursing assistants (GNAs) reviewed during the annual survey. The Assistant Director of Nursing (ADON) was unable to provide evidence of completed performance reviews for these GNAs within the past 12 months, despite being given the opportunity to search for the missing documentation. The ADON confirmed that the annual performance reviews could not be located. Further inquiry with the Human Resources (HR) representative revealed that the process for performance reviews involved notifying supervisors of upcoming due dates and expecting completed forms to be returned. However, the HR representative relied primarily on verbal reminders and did not have a system to ensure completion or follow-up if reviews were not received. Both the Director of Nursing and ADON were informed of the missing annual performance reviews for the five GNAs.
Failure to Post Actual Nursing Staff Hours Worked
Penalty
Summary
Facility staff failed to post the actual hours worked per shift for Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Medication Aides (CMA), and Geriatric Nursing Assistants (GNA) on two units. During multiple observations between 08/04/25 and 08/13/25, surveyors noted that while staff names and assignments were listed on the whiteboard and Resident Care Staffing Report sheets, the section designated for actual hours worked was consistently left blank. Interviews with the Unit Manager revealed a lack of awareness regarding the requirement to post actual hours worked for each nursing staff member. These findings were communicated to the Director of Nursing at the conclusion of the survey period.
Failure to Consistently Sign Narcotic Record Books by Nursing Staff
Penalty
Summary
The facility failed to ensure that narcotic record books were consistently signed by both incoming and outgoing nurses, as required by facility protocol. During a medication administration observation, surveyors found multiple missing signatures in the narcotic record books, with omissions dating back several months and including recent weekend shifts. Staff confirmed that the protocol required both nurses to sign the narcotic record book at each shift change, but acknowledged that this was not consistently done. In one instance, an LPN admitted to counting narcotics with the outgoing nurse but failed to sign the record book until prompted by the surveyor. Further review of employee files revealed that at least one RN had a history of corrective action notices related to failure to perform narcotic count sign-off with the off-going nurse, with documentation of repeated incidents before and after a specific date. The Director of Nursing confirmed awareness of the issue and reiterated the facility's expectation for both nurses to sign the narcotic record book to ensure accountability and prevent discrepancies.
Failure to Address Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that medication regimen review (MRR) recommendations made by the consulting pharmacist were addressed by the provider for several residents. In one case, a resident was prescribed multiple psychotropic medications, including Alprazolam, Gabapentin, and Quetiapine. The pharmacist recommended a gradual dose reduction (GDR) for these medications, but there was no evidence that the resident was re-evaluated by psychiatry after the recommendation. Additionally, the medical director increased the resident's Seroquel dosage without documenting the rationale or addressing the pharmacist's GDR recommendation. Interviews with the DON and medical director confirmed that no documentation was available to support the clinical decisions or to show that the pharmacist's recommendations were considered. For another resident, the facility's records showed that the pharmacist identified irregularities in the MRRs on two separate occasions. However, there was no documentation in the medical record indicating that these irregularities were addressed by the provider. The DON acknowledged the concern when interviewed and confirmed that the provider did not respond to the pharmacist's recommendations. A third resident's records revealed that the pharmacist recommended a GDR for several psychotropic medications, but the provider did not respond to these recommendations or make adjustments to the medications until several months later. There was also no documentation from the physician indicating agreement or disagreement with the pharmacist's recommendations, nor evidence of non-pharmacological interventions being provided. The DON was unable to provide documentation of such interventions when asked.
Failure to Ensure Resident Was Free from Unnecessary Psychotropic Medications
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, depression, anxiety, and cerebral aneurysm, was not ensured to be free from unnecessary psychotropic medications. The resident was unable to complete the BIMS assessment, indicating significant cognitive impairment. Pharmacy medication regimen review in June recommended a gradual dose reduction (GDR) for several psychotropic medications, including Alprazolam, Gabapentin, and Quetiapine. Despite this recommendation, there was no evidence that the resident was re-evaluated by psychiatry after the pharmacy's suggestion, and the GDR was not implemented. Additionally, the Medical Director increased the resident's Seroquel dosage without documenting the rationale, the discussion regarding the pharmacy's GDR recommendation, or the use of non-pharmacological interventions prior to the medication increase. Progress notes did not reflect any attempt at non-pharmacological interventions when the resident exhibited agitation and aggression. Interviews with the DON and Medical Director confirmed that there was no documentation supporting the need for the additional medication or evidence of attempted non-pharmacological interventions, and the Medical Director acknowledged the lack of documentation and intervention as an error.
Medication Labeling and Storage Deficiencies with Incomplete Refrigerator Temperature Monitoring
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of medications, as well as consistent temperature monitoring for medication refrigerators. During medication administration observations, several opened bottles of house stock medications, including Melatonin, Vitamin B12, Magnesium Oxide, Guaifenesin, Aspirin, and Bisacodyl, were found without open dates on two medication carts. Interviews with nursing staff confirmed that the facility's expectation was for all opened house stock medications to be dated upon opening, but this was not consistently followed. Additionally, in one medication storage room, the refrigerator temperature log was found to be incomplete, with missing signatures and entries for several days and shifts across multiple months. The unit manager confirmed that temperatures were expected to be checked and documented twice daily, but this was not consistently done, as evidenced by gaps in the June and July logs. These findings demonstrate lapses in medication management practices as observed and documented by surveyors.
Failure to Timely Refer Resident for Dental Services
Penalty
Summary
Facility staff failed to refer a resident with worn down dentures for dental services in a timely manner. The resident repeatedly reported issues with chewing, sore gums, and difficulty eating due to ill-fitting dentures. These concerns were documented by the Registered Dietitian (RD) on multiple occasions, who also notified the kitchen, speech language pathologist (SLP), and activities personnel. However, there was no documentation indicating that any dental follow-up was initiated by these staff members. The SLP assessed the resident and recommended a change to a pureed diet due to the denture issues, but did not document any referral for dental services. The Social Worker Assistant (SW) was unaware of the resident's dental concerns until several months after the initial reports, indicating a breakdown in communication among staff. The Director of Nursing (DON) acknowledged that interventions to address the resident's dental needs were delayed. Despite the resident's ongoing complaints and requests for new dentures, no timely action was taken to ensure the resident received appropriate dental care, resulting in a deficiency related to the provision and coordination of dental services.
Incomplete PASARR and Medical Record Documentation
Penalty
Summary
Facility staff failed to ensure that resident medical records were complete and accurate, and that records were properly maintained, as evidenced by several deficiencies in the handling of Preadmission Screening and Resident Review (PASARR) documentation and wound care records. For three residents reviewed for PASARR, there were incomplete or missing sections in the required forms. In one case, a PASARR form had an entire section left blank despite instructions to complete it if certain criteria were met. Another resident's PASARR form was missing a required section, and staff acknowledged that the form should have been completed in its entirety. For a third resident, documentation indicated a need for a Level II screening, but the facility did not have the necessary follow-up documentation on file, despite staff expectations that such records should be maintained. Additionally, for one resident reviewed during the annual survey, the facility failed to maintain complete skin and wound documentation following the resident's discharge to a hospital. The medical record lacked any skin and wound documentation after a specific date, and the facility was unable to provide information about the hospital to which the resident was sent. These findings demonstrate lapses in the facility's processes for maintaining accurate and complete medical records in accordance with professional standards.
Failure to Prevent Cross-Contamination in Laundry Room
Penalty
Summary
The facility failed to ensure proper storage and processing of linen to prevent the spread of infection. During an observation of the laundry room, it was noted that dirty linen was stored in bins in one room, while clean, folded linen was left uncovered on tables in an adjacent room. The door separating the two rooms was left open, allowing for potential cross-contamination between clean and dirty linens. An interview with the Director of Housekeeping revealed that the door had routinely been kept open, and he was unaware that this practice posed an infection control concern. The Director of Nursing was made aware of the issue during the survey.
Failure to Document and Administer Required Immunizations
Penalty
Summary
The facility failed to ensure that residents were properly screened for and/or received pneumococcal and influenza vaccinations as required. During record review, it was found that one resident did not have any documentation of receiving either the pneumococcal or influenza vaccines, while another resident lacked documentation for the pneumococcal vaccine. The Director of Nursing acknowledged during an interview that there was not an effective process in place for maintaining resident immunization records and was aware of the issue.
Failure to Screen and Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that all residents were screened for and offered the COVID-19 vaccination, as required. During a review of immunization records for five residents, it was found that two residents did not have any documentation indicating they had been screened for or offered the COVID-19 vaccine. This lack of documentation was confirmed during an interview with the Director of Nursing, who acknowledged that the facility did not have an adequate process in place for resident immunization screening and documentation. The deficiency was identified through both record review and staff interview, with specific reference to the absence of required documentation for two residents regarding COVID-19 vaccination screening and offering.
Environmental Safety and Cleanliness Deficiencies Identified
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents and staff, as evidenced by several observed deficiencies. On the Chesapeake unit, a locked closet with a damaged door revealed an exposed latch visible from the hallway, and a soiled utility room was found to have cracked floor tiles in front of a drain. Additionally, a shower stall on another unit contained a dark or black substance between the tiles, extending from the floor up to the steel grab bar, with the substance being more pronounced in the corners. Further observations on the Chesapeake unit revealed that the entrance doors to several rooms were cracked and missing coating near the lower door hinge. These findings were based on direct observations during the annual survey and indicate multiple areas where the physical environment was not adequately maintained for safety and comfort.
Deficiency in Pest Control Measures for Flies in Food Service and Resident Care Areas
Penalty
Summary
Surveyors identified a deficiency in the facility's pest control program, specifically related to the presence of flies in both food service and resident care areas. Multiple flies were observed in a resident's room while the resident was resting in bed, and the resident confirmed that flies were often present. Additional flies were seen in the kitchen during food service operations, with staff attributing the issue to the kitchen exit door being left open, which allowed flies to enter from the refuse area located directly outside. Flies were also observed in the hallway and around food carts as meals were being delivered to residents. Interviews with staff revealed that the pest control company visited the facility biweekly or as needed, and that sticky traps were used in various parts of the building. The Maintenance Director stated that pest control services included spraying chemicals in hallways and near doorways, as well as treating the exterior of the building, but only once in the spring and once in the fall. He also indicated that he relied on staff and residents to report pest sightings and was not previously aware of the fly issue in the kitchen. During a walk-through, several fly traps were observed, but flies remained present in the food preparation area and resident care areas.
Lack of Documented QAPI Training for Staff
Penalty
Summary
The facility failed to provide required annual Quality Assurance and Performance Improvement (QAPI) training to its staff, as evidenced by the absence of documentation in the employee files of seven staff members reviewed during the annual survey. During interviews, the Assistant Director of Nursing (ADON) stated that ongoing training occurs twice per month and that an annual competency skills fair was held, but was unable to produce records verifying completion of QAPI training for the specified staff. Despite a subsequent search and provision of additional education records, there remained no evidence of QAPI training for the employees in question. Both the Director of Nursing and the ADON were informed of the missing documentation.
Lack of Documented Infection Control Training for Staff
Penalty
Summary
The facility failed to provide mandatory infection prevention and control training to its staff as required by its infection prevention and control program. During the annual survey, interviews with the Assistant Director of Nursing (ADON) revealed that ongoing training was conducted twice per month and an annual competency skills fair was held. However, upon review of the employee files for seven staff members, there was no documentation verifying completion of the required infection prevention and control training for the current year. Despite additional attempts by the ADON to locate the records, no evidence of the required training was found in the files provided to the surveyor. Both the Director of Nursing and the ADON were informed of the missing documentation.
Lack of Compliance and Ethics Training Documentation for Staff
Penalty
Summary
The facility failed to provide staff with compliance and ethics training, as evidenced by the absence of documentation in the employee files reviewed during the annual survey. Seven employee files, including those of geriatric nursing assistants, an LPN, and an RN, were examined at the request of the surveyor. The Assistant Director of Nursing (ADON) stated that ongoing training occurs twice per month and that an annual competency skills fair was held, but was unable to produce records verifying that compliance and ethics training had been completed for the current year. Despite a subsequent search and provision of additional education records, no evidence of compliance and ethics training was found for any of the sampled staff. Both the Director of Nursing and the ADON were informed of these findings.
Failure to Provide Required Annual In-Service Training for GNAs
Penalty
Summary
The facility failed to provide geriatric nursing assistants (GNAs) with the required annual in-service training, as evidenced by a review of five GNA employee files during the annual survey. The Assistant Director of Nursing (ADON) stated that ongoing training was conducted twice per month and that an annual competency skills fair was held, but when asked to provide documentation of annual in-service training for the GNAs, no such records were found in the employee files. Despite a subsequent search and provision of additional education records, there was still no evidence of the required annual in-service training for the five GNAs reviewed. Both the Director of Nursing and the ADON were informed of the missing documentation. No information was provided regarding the medical history or condition of any residents at the time of the deficiency, and the report focuses solely on the lack of required staff training documentation.
Lack of Documented Dementia Training for Staff
Penalty
Summary
The facility failed to provide required dementia training to its staff, as evidenced by the absence of documentation in the employee files of all seven staff members reviewed during the annual survey. The Assistant Director of Nursing (ADON) stated that ongoing training occurs twice per month and that an annual competency skills fair was held, but when asked to provide records verifying completion of dementia training for the current year, no such documentation was found in the files of the geriatric nursing assistants, LPN, or RN reviewed. Despite a subsequent search and provision of additional education records by the ADON, there remained no evidence of dementia training for these staff members. Both the Director of Nursing and ADON were informed of these findings by the surveyor.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
