Complete Care At Annapolis
Inspection history, citations, penalties and survey trends for this long-term care facility in Annapolis, Maryland.
- Location
- 900 Van Buren Street, Annapolis, Maryland 21403
- CMS Provider Number
- 215005
- Inspections on file
- 18
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Complete Care At Annapolis during CMS and state inspections, most recent first.
Failure to provide quarterly resident fund statements: several residents reported not receiving account statements for personal funds held by the facility. The BOM said statements were given monthly on request and quarterly otherwise, with signed acknowledgments kept, but record review found no proof that the affected residents received their statements. The NHA said statements were provided in person to capable residents and mailed or emailed to residents with responsible parties, but acknowledged the concern.
A deaf resident with a communication-sensory impairment had a VRI tablet available in the room and a posted sign indicating deafness, but staff primarily relied on written notes, facial expressions, and gestures instead of using the VRI system. The resident reported that written communication was not the preferred method and that staff rarely used the VRI device. When asked by surveyors, a GNA and an LPN were unable to obtain an interpreter through the VRI system because they did not know how to operate it, despite the DON’s stated expectation that VRI be used throughout the day for this resident.
Failure to timely revise and implement fall care plans affected two residents. One resident with a history of multiple falls had a post-fall care plan that included neuro-checks, but the DON stated there was no evidence they were completed, and the resident’s bed was observed in a high position despite fall-risk interventions. Another resident who had an unwitnessed fall, was on Plavix, and later reported a hip fracture had care plan revisions made 3 days after the fall, but the facility could not provide evidence that ordered neuro-checks were completed.
Failure to provide oral hygiene and showers to dependent residents. One resident required partial/moderate assist with oral care, had an ADL self-care deficit related to fatigue and tremors, and was documented as not receiving oral hygiene on multiple days despite the facility’s twice-daily protocol. Another resident with limited mobility and dependence for showers reported not having a shower for 5 weeks; records showed only one shower in the prior 30 days, despite a schedule for twice-weekly showers and a preference for shower vs bed bath.
Oxygen tubing was not dated or labeled for two residents receiving O2 via nasal cannula. One resident had continuous O2 for COPD and the other had O2 PRN for SOB; both had orders for weekly tubing and humidifier changes with labeling after each change. During observations, an LPN, RN, and DON confirmed the expectation that tubing should be changed weekly and dated.
Late Administration of Time-Sensitive Seizure Medications: A resident reported that seizure medications were being given late, and audit findings confirmed multiple late administrations of Levetiracetam and Lamotrigine by nursing staff. The DON reviewed the findings and confirmed that staff are expected to administer medications within a 1-hour window before to 1-hour after the due time.
Failure to Follow Resident Meal Preferences: Two residents were observed receiving meals that did not match their meal tickets. One resident was served regular portions despite a ticket for large portions, and the resident said this mismatch happened many times. Another resident was served peas and carrots even though the ticket specified green beans and no peas. The Food Director and staff confirmed the discrepancies, and the DON was notified of the meal preference concerns.
Food Storage and Labeling Deficiencies: During a kitchen tour, multiple food items were found without expiration dates, including non-perishable and perishable products, and several expired items were observed in storage. In the fridge, 6 containers of cooked foods lacked labels identifying the items and had no discard dates, despite the FSD stating that cooked foods should be labeled with the item name and use-by date.
The facility failed to report an elopement and an abuse allegation within the required timeframes. A resident with severe cognitive impairment eloped and was missing for a short period, but the incident was reported to the OHCQ much later than required. Additionally, an abuse allegation was reported to the State Agency several hours after it was made. The DON confirmed the reporting delays, and the staff involved are no longer employed at the facility.
Two residents with severe cognitive impairment eloped from the facility due to inadequate supervision. One resident left through a window, while another exited through a malfunctioning door. Both incidents occurred despite functioning wander guards and door alarms, highlighting a failure in monitoring and security measures.
The facility did not follow up on pharmacy recommendations for two residents, leading to delays in necessary evaluations and tests. One resident on Quetiapine did not receive an AIMS evaluation as recommended, and another on Atorvastatin did not have a fasting lipid panel conducted in a timely manner. The facility's process for addressing pharmacy recommendations was not effectively followed, resulting in these deficiencies.
A resident was transferred to the hospital for altered mental status, but the facility failed to provide written notification of the transfer reason to the resident and their representative. Staff confirmed that the reason was communicated verbally, but not documented in writing, and the transfer form was not mailed as the resident returned within 24 hours.
A facility failed to provide a resident and their representative with written notification of the bed-hold policy upon the resident's transfer to a hospital. Although the policy was included in the transfer packet sent to the hospital, it was not given to the resident or their representative. Interviews with LPNs and the DON confirmed the lack of written notification, and the DON could not find documentation to show that the policy was mailed to the resident's representative.
A facility failed to provide and document an activities program for a resident with physical limitations, as outlined in the care plan. The resident's care plan included music therapy and in-room activities, but there was no documentation of these activities in the electronic record. Interviews revealed inconsistencies in performing and documenting the activities, with the Activities Director admitting to lapses in maintaining records.
An LPN failed to instruct a resident with COPD to rinse their mouth after administering Trelegy inhalation, as per the physician's order. This oversight was identified during a medication observation, and the Director of Nursing confirmed the error.
A facility failed to provide necessary respiratory care for a resident with a tracheostomy by not implementing a physician's order for a speaking valve replacement. The resident reported that their Passy-Muir valve had not been changed since their arrival, despite having prescriptions from an ENT physician. The unit manager was aware of the prescriptions but believed the respiratory therapist would supply the equipment. The DON was unaware of the issue, and the Administrator only learned of the prescriptions on the survey day.
Failure to Provide Quarterly Resident Fund Statements
Penalty
Summary
The facility failed to ensure that quarterly resident fund account statements were provided to residents for personal money deposited with the nursing home. During resident interviews, four residents stated they did not receive statements or did not always receive them: one resident said he or she did not receive a quarterly statement, another said he or she had an account but had never received statements and requested them, a third said he or she had never received a statement of account, and a fourth said he or she did not always receive quarterly fund statements. The Business Office Manager stated that statements were given monthly to residents who requested them and quarterly to all other residents, and that a binder was maintained to document distribution. She later stated that residents or responsible parties were to sign a copy of the receipt as acknowledgment of receiving the statement. Review of the statements for the residents who reported not receiving them did not show acknowledgments that the statements had been received, and the Business Office Manager confirmed there was no evidence that those residents had received the quarterly statements. The Nursing Home Administrator stated that statements were provided in person to capable residents and mailed or emailed to residents with responsible parties quarterly or per request, with acknowledged copies kept, and acknowledged the concern when informed of the issue.
Failure to Utilize Video Remote Interpreting for Deaf Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to utilize Video Remote Interpreting (VRI) services for a deaf resident with communication-sensory impairment. A sign outside the resident’s room indicated the resident was deaf, and a VRI tablet was present in the room. Multiple staff members, including two geriatric nurse assistants and an LPN, reported that they communicated with the resident primarily through written communication, facial expressions, and gestures. The resident stated that written communication was not their preferred method of communication and reported that staff rarely used the VRI tablet. Further observations and interviews showed that staff were not effectively using the VRI system despite the facility’s expectation that it be used throughout the day during care for this resident. When the surveyor asked a geriatric nurse assistant and an LPN to obtain an interpreter through the VRI system, both were unable to do so because they did not know how to use it. The DON confirmed that the expectation was for staff to use the VRI system for this resident, and the Assistant DON acknowledged understanding of the concern when it was presented. These findings demonstrate that the resident’s preferred communication method via VRI was not being implemented in practice.
Failure to Timely Revise and Implement Fall Care Plans
Penalty
Summary
The facility failed to revise residents’ care plans in a timely manner and failed to implement care plan interventions for 2 residents reviewed for falls. Resident #93 had an actual fall on 1/13/2025 and was identified in the care plan as high risk for falls related to deconditioning and a history of multiple falls. The care plan included neuro-checks, but when the facility was asked for evidence that the checks were completed, the DON stated there was no evidence they were done. During interviews and observations, Resident #93’s bed was noted to be in a high position, and the DON stated the care plan revisions should have included keeping the bed in the lowest position with the wheels locked. Resident #8 reported falling off the bed in January 2026, fracturing a hip, and being sent to the hospital. The medical record showed an unwitnessed fall on 1/6/2026, and the resident was taking Plavix. The care plan was revised 3 days after the fall and stated to continue at-risk plans and perform neuro-checks per facility policy, but the facility could not provide evidence that the neuro-checks were completed. The DON stated that after a resident fall, a post-fall assessment, updated care plan, vital signs, and neurological assessment should be completed per facility protocol, and acknowledged that the care plan revisions for Resident #8 were not revised in a timely manner.
Failure to Provide Oral Hygiene and Showers to Dependent Residents
Penalty
Summary
The facility failed to provide oral hygiene care and showers to dependent residents. Resident #93 reported that no one at the facility cleaned their teeth and that a family member came in once a week to assist with oral hygiene. The resident’s MDS Section GG indicated partial/moderate assistance was required for oral hygiene, and the care plan identified an ADL self-care deficit related to fatigue and tremors to the upper extremities, with extensive assistance needed to maximize independence. The resident also stated during follow-up that they had not received oral care in the morning. Review of the electronic record showed several oral hygiene task entries marked not applicable, and the DON stated she was not aware what that meant. The DON later stated the facility protocol was to provide oral hygiene twice daily, but the resident’s documentation showed 7 of 30 days without oral care per protocol. Resident #86 reported not having had a shower for the last 5 weeks and said they would like showers more often if given the opportunity. The resident’s care plan identified a self-care performance deficit related to limited mobility and stated the resident was totally dependent on staff to provide showers on preferred days. The shower schedule showed showers were to be provided on Mondays and Thursdays, and the MDS Section GG coded the resident as requiring partial/moderate assistance for showers. Facility shower records from the prior 30 days showed the resident showered only once. A staff member confirmed that GNAs were responsible for offering and providing showers and stated she had not given the resident a shower or assisted with one during the last 30 days.
Oxygen Tubing Not Dated or Labeled
Penalty
Summary
The facility failed to ensure that oxygen administration equipment was dated and labeled after being changed in accordance with physician orders and facility expectations. During the initial tour, Resident #109 was observed eating breakfast in bed while receiving oxygen at 2 LPM via nasal cannula, and the tubing had no date or label. Resident #20 was also observed in bed preparing to eat breakfast while receiving oxygen at approximately 1.8 LPM via nasal cannula, and that tubing also had no date or label. Review of physician orders showed that Resident #20 had an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath, with the humidifier bottle and tubing to be changed weekly and as needed if visibly soiled, and each component labeled with the date and staff initials, scheduled every Sunday on the night shift. Resident #109 had an order for oxygen at 2 L/min via nasal cannula continuously for COPD, with the humidifier bottle and tubing to be changed weekly and each component labeled with the date and staff initials, scheduled every Sunday on the night shift. Follow-up observations showed Resident #109's tubing still without a date or label, and Resident #20's tubing also remained without a date or label. An LPN and an RN stated that oxygen tubing should be changed weekly and dated, and the DON stated that tubing should be changed weekly on Sundays and dated after each change.
Late Administration of Time-Sensitive Seizure Medications
Penalty
Summary
The facility failed to administer time-sensitive seizure medications on time for Resident #108. During an interview on 3/03/2026, the resident stated that staff had been giving seizure medications late. A review of the Medication Administration Audit on 3/10/2026 showed that Levetiracetam 1000 mg, ordered for 9:00 PM on 3/1/2026, was administered at 9:24 AM on 3/2/2026 by Staff #26. The audit also showed that Lamotrigine 150 mg, ordered for 5:00 PM on 3/6/2026, was administered at 8:25 PM the same day by Staff #27. The audit further showed that Levetiracetam 1000 mg, ordered for 9:00 PM on 3/7/2026, was administered at 10:15 PM by Staff #18. The report states that Lamotrigine is a time-sensitive medication requiring strict adherence to a specific dosing and titration schedule to maintain safety and efficacy, and that timely administration of Levetiracetam is medically critical because of its relatively short half-life and the high risk of breakthrough seizures associated with inconsistent blood levels. The DON was informed of the resident’s concern and the audit findings and confirmed them, stating that nursing staff are expected to give medications within a 1-hour window before to 1-hour after the due time.
Failure to Follow Resident Meal Preferences
Penalty
Summary
The facility failed to provide food in accordance with resident preferences for 2 of 4 residents reviewed during the dining observation. Resident #8 was observed at lunch receiving regular portions even though the meal ticket indicated large portions. During a brief interview, the resident stated that the meal ticket did not match what was served and said this happened "so many times." The Food Director reviewed the meal portions and confirmed that the portions served were regular and not large as indicated on the ticket. Resident #39 was observed at lunch receiving peas and carrots even though the meal ticket stated to serve green beans and not to serve peas. The resident reported not eating the peas and carrots. Staff confirmed that Resident #39 was not served green beans and also confirmed that the meal ticket indicated the resident should not be served peas. The Food Director stated that updating resident meal preferences was the dietician's responsibility and that if a resident had a pattern of refusing certain meals or portions, the facility expected the meal preferences to be honored and the meal tickets updated as soon as possible.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food products in accordance with professional standards for food safety during an initial kitchen tour. In the kitchen storage areas, a Turkey Gravy Mix was observed without an expiration date, although the received date of 2/23/2026 was printed on it. Other non-perishable items without expiration dates included a bottle of maple syrup, and perishable items without expiration dates included a bag of frozen corn dogs, a bag of frozen meatballs, and a container of garlic. Expired items were also found, including 4 bags of bread rolls with an expiration date of 2/26/2026, a bottle of Teriyaki sauce with an expiration date of November 2025, and a container of peeled boiled eggs with an expiration date of 2/26/2026. During the fridge tour, 6 containers of cooked foods were observed without labels identifying the items and without dates to discard them. The Food Service Director stated that cooked foods should be labeled with the name of the item and the expiration or use-by date.
Failure to Timely Report Elopement and Abuse Allegations
Penalty
Summary
The facility staff failed to report an alleged elopement violation within the required two-hour timeframe to the Office of Health Care Quality (OHCQ). On the morning of May 2, 2024, a Geriatric Nursing Assistant (GNA) discovered that a resident with severe cognitive impairment was missing from their room. The resident was last seen at approximately 6:30 AM, and the local police were notified at 7:20 AM. The resident returned to the facility at 8:30 AM. However, the initial incident report was not submitted to OHCQ until 5:23 PM, which did not meet the two-hour reporting requirement. The resident had been care planned for being at risk of elopement due to impaired safety awareness. Additionally, the facility failed to report an allegation of abuse within the required timeframe. An allegation was made by a resident on August 24, 2022, at 5:10 AM, but the Self Report Form was not submitted to the State Agency until 3:00 PM the same day. The Director of Nursing (DON) confirmed that the allegation should have been reported within two hours. The staff involved in the reporting of this incident no longer work at the facility.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent the elopement of two residents with severe cognitive impairment. Resident #98 was last seen in their room early in the morning and was later found missing. The resident, who was alert and oriented only to self, was discovered to have left the facility without staff observation. The investigation revealed that the resident likely climbed out of a window, as all door alarms and the resident's wander guard bracelet were functioning properly. The resident returned to the facility on their own after being gone for nearly one and a half hours. In a separate incident, Resident #29 was found outside the facility in a wheelchair by rehab staff. The resident, who also had severe cognitive impairment, indicated they exited through a side door. Upon investigation, it was found that the door was slightly ajar, and the alarm did not activate when the resident exited, despite the resident wearing a functioning wander guard. The Nursing Home Administrator confirmed the door malfunctioned, allowing the resident to leave the building without triggering an alarm. Both incidents highlight the facility's failure to adequately supervise residents at risk of elopement. Despite having systems in place, such as wander guards and door alarms, the facility did not prevent these residents from leaving the premises unsupervised. The lack of staff awareness and the malfunctioning of security measures contributed to these deficiencies, putting the residents at risk.
Failure to Follow Up on Pharmacy Recommendations
Penalty
Summary
The facility failed to follow up on pharmacy recommendations after monthly drug regimen reviews, as evidenced by the cases of two residents. For one resident, the pharmacist recommended an Abnormal Involuntary Movement Scale (AIMS) evaluation due to the use of Quetiapine, an antipsychotic medication. This recommendation was made in September and November, but the physician was not informed, and the evaluation was not conducted. The facility's policy requires that all recommendations be addressed within 30 days, but this was not adhered to in this case. For another resident, the pharmacist recommended a fasting lipid panel due to the use of Atorvastatin, a cholesterol-lowering medication. This recommendation was made in October but was not carried out until December, after the pharmacist reiterated the recommendation. The facility's process involves the pharmacist entering notes into the electronic record, which are then accessed by the DON and ADON. The ADON is responsible for ensuring that unit managers discuss recommendations with physicians and obtain their feedback. However, this process was not effectively followed, leading to delays in addressing the pharmacist's recommendations.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility staff failed to provide written notification to a resident and their representative regarding the reason for a transfer to the hospital. This deficiency was identified during a recertification/complaint survey for a resident who was hospitalized. The resident was sent to the emergency room due to altered mental status, but there was no documentation or evidence that the resident or their representative was notified in writing about the transfer and its reason. Interviews with facility staff, including two LPNs and the Director of Nursing, revealed that the reason for the transfer was communicated verbally to the resident and their representative, but not in writing. The Director of Nursing confirmed that although the reason for transfer was documented in the transfer form sent with the resident to the hospital, there was no documentation to show that this information was mailed to the resident's representative. The facility did not mail the transfer form because the resident returned to the facility within 24 hours.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident and their representative in writing of the bed-hold policy upon the resident's transfer to an acute care facility. This deficiency was identified during a recertification/complaint survey for a resident who was hospitalized. The resident was sent to the emergency room due to altered mental status, and although the resident's daughter was present at the time of transfer, there was no documentation indicating that the facility provided written notification of the bed-hold policy. Interviews with two Licensed Practical Nurses (LPNs) revealed that while the bed-hold policy was included in the transfer packet sent to the hospital, it was not given to the resident or their representative. Both LPNs confirmed that they had never provided written notification of the bed-hold policy to residents or their representatives. The Director of Nursing (DON) stated that the bed-hold policy was typically sent with the transfer packet to the hospital and a copy mailed to the resident's representative by the Nursing Home Administrator. However, the DON could not find any documentation to show that the resident or their representative received written notification of the bed-hold policy. A review of the change in condition and transfer form confirmed that the bed-hold policy was not included in the packet sent with the resident. The DON acknowledged that the facility missed providing the transfer notice and bed-hold policy to this particular resident.
Failure to Provide and Document Resident Activities
Penalty
Summary
The facility staff failed to provide an activities program that met the needs and preferences of a resident, as evidenced by the lack of performance and documentation of activities per the resident's care plan. The care plan for the resident, who had physical limitations, included a goal for participation in in-room activities of choice, such as music therapy, once a day and three times a week. However, the surveyor found no documentation of these activities in the resident's electronic record, and interviews with staff revealed inconsistencies in the execution and documentation of the activities. During interviews, the resident's mother expressed concerns that the activity staff had not engaged with the resident as outlined in the care plan. The unit manager was unaware of the specific activities conducted with the resident, and the Activities Director admitted to inconsistencies in providing and documenting the activities. The Activities Director also acknowledged that the participation log sheets, which were supposed to be transferred to the electronic record, were not maintained, resulting in a lack of documentation for the activities performed with the resident.
Failure to Instruct Resident to Rinse Mouth After Inhaler Use
Penalty
Summary
The facility failed to ensure that a resident received appropriate care according to physician orders during a medication administration observation. Specifically, a Licensed Practical Nurse (LPN) administered Trelegy inhalation to a resident with chronic obstructive pulmonary disease (COPD) but did not instruct the resident to rinse their mouth afterward, as required by the physician's order. This oversight was identified during a recertification/complaint survey, where it was noted that the physician's order, dated five days prior, explicitly stated the need for the resident to rinse their mouth after using the inhaler. The Director of Nursing confirmed the findings during an interview, acknowledging the nurse's error in not following the complete order instructions.
Failure to Implement Physician's Order for Tracheostomy Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident with a tracheostomy by not implementing the physician's order for a speaking valve replacement. The resident, who had been at the facility for about a year, reported to the surveyor that their Passy-Muir valve had not been changed since their arrival, despite having prescriptions from an ENT physician for a speaking valve since April 2024 and another prescription for the same valve and a tracheostomy collar in November 2024. The resident provided a copy of the prescription to the surveyor, indicating that the facility had not acted on these orders. During interviews, the unit manager acknowledged awareness of the prescriptions but mistakenly believed the respiratory therapist would supply the necessary equipment. The Director of Nursing was unaware of the issue, and the Administrator only became aware of the prescriptions on the day of the survey through the resident's responsible party. The facility had not yet received the supplies, as they were waiting for delivery through the Administrator.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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