Complete Care At Hagerstown
Inspection history, citations, penalties and survey trends for this long-term care facility in Hagerstown, Maryland.
- Location
- 14014 Marsh Pike, Hagerstown, Maryland 21742
- CMS Provider Number
- 215365
- Inspections on file
- 19
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Complete Care At Hagerstown during CMS and state inspections, most recent first.
Staff failed to maintain a homelike environment when a water-stained ceiling tile and damaged drywall behind a bed in two resident rooms were not identified or reported. While the Maintenance Director stated that weekly and monthly audits are conducted and that staff are expected to submit work orders through TELS, no work orders were received for these issues. The DON did not believe any work orders had been submitted, a GNA reported not noticing the damaged drywall, and an RN acknowledged not paying attention to maintenance concerns during rounds, allowing the environmental damage to remain unaddressed in the residents’ rooms.
Facility staff failed to clarify and correctly implement a verbal IV fluid order for a resident receiving Lactated Ringers for dehydration. The EHR showed an order for IV fluids at a specified rate for 2 days, with documentation of administration on two days but no record of fluids being given on the subsequent day. The DON later explained that the intended regimen was multiple liters over 2 days, but described the order as poorly written and confusing, and acknowledged it was not clarified. An NP note documented IV fluids to continue for 48 hours, but the NP later stated this was a typo and that a new order was written in error when a new IV bag was started, contributing to the resident not receiving the full intended course of IV fluids.
A resident admitted with talar osteomyelitis of the left foot had additional wounds documented by the admitting nurse, including a scab on the left ankle, a sore on the left foot, and a sore on the left heel, but no wound treatment orders were obtained at admission. The attending physician repeated the hospital osteomyelitis note, documented no skin lesions, did not address the additional wounds, and did not initiate wound care, stating later that a wound specialist handles such care. The wound NP did not assess the resident until 10 days after admission, at which time a venous ulcer on the left medial malleolus, a left plantar diabetic foot ulcer, and an unstageable pressure ulcer on the left heel were identified and treatment started. The DON reported that the admitting LPN should have clarified the discharge instructions and notified the physician for orders for all identified wounds.
A cognitively impaired resident with a history of hemorrhagic stroke was incorrectly assessed on admission as unable to ambulate, which locked the elopement assessment and led to the resident being classified as not at risk for elopement despite prior functional independence and hospital therapy notes showing ambulation with a walker. After admission, the resident experienced falls while trying to walk, was documented as severely cognitively impaired and incapable of making decisions, and demonstrated improved mobility, poor safety awareness, wandering, and frequent statements about wanting to go home, but the facility did not reassess elopement risk or implement elopement precautions. On the day of the incident, the resident walked down the hall carrying personal items, exited the front door unchallenged while assigned staff were passing dinner trays, and was later found by a visitor lying on the ground in the parking lot in dark, cold conditions, having fallen and sustained abrasions and scrapes, while staff and leadership acknowledged that the resident had not been identified or monitored as an elopement risk.
Facility staff did not conduct required annual performance evaluations for multiple GNAs, preventing systematic identification of skill weaknesses and related training needs. Review of employee files showed that several GNAs hired for more than a year had no documented performance evaluation within the past year. In an interview, the DON and NHA confirmed there was no established process to ensure annual performance evaluations for nurse aides, resulting in a failure to monitor and assess aide performance as required.
Facility administration permitted a nephrology NP to conduct consultations, including on new admissions, without an executed contract and without required physician orders, in violation of facility policy. One resident’s consult documented a medication error that the NP did not report to staff, and the issue was only identified later by surveyors. Additional residents were also seen by this NP over several months with consult notes uploaded days after visits and no corresponding nephrology orders. The medical director reported that nephrology consults should be based on diagnosed need and attending physician orders, was not overseeing these consults, and confirmed there was no nephrologist signing off on the NP’s work.
Facility staff did not maintain an effective training program for all personnel. Orientation materials lacked behavioral health content based on the facility assessment, and the infection control module omitted the facility’s own infection prevention and control policies and procedures. Multiple GNAs, an LPN, and a laundry aide were not current with required computer-based trainings, including abuse, Resident Rights, and infection control. Corporate assigned annual CBT modules, but there was no system in place at the facility level to ensure staff completed the required education, and leadership could not provide a rationale for these deficiencies.
Facility staff failed to establish and implement a comprehensive nurse aide training program that ensured each aide received at least 12 hours of annual education, including dementia care, abuse prevention, and skills competencies. Review of three aides’ personnel files and computer-based training transcripts showed no documented annual performance evaluations and no evidence of completing the required 12 hours of competency-based training within the past year. The existing nurse aide training plan consisted only of computer-based modules without skills competency components, and leadership staff, including the NHA and acting Nurse Practice Educator, confirmed that a formal nurse aide training program had not been developed or implemented.
The facility failed to timely report multiple allegations of abuse, neglect, and injuries of unknown origin to the State Agency within required timeframes. In separate incidents, a resident reported inappropriate touching, another had a bruise and discoloration to the right knee and shin first identified by family, a ventilator‑dependent resident experienced loud and aggressive behavior and threatening statements from an RT, and another resident reported pain after an improper transfer to a bedside commode. In each case, staff such as a UM, RN, LPN, and other management were aware of the concerns earlier than the times documented in reports to the SA, delayed notifying leadership, or did not escalate the concerns as required, resulting in reports being submitted hours to days after the initial allegations or discovery of injuries.
Staff failed to uphold resident dignity and self-determination when one resident repeatedly and loudly requested help to use the bathroom due to stomach pain and fear of incontinence while an LPN at the nurses’ station acknowledged the need but continued medication tasks and phone use without providing or arranging timely toileting, leaving another staff member to address the ADL need only after a significant delay. In a separate case, a cognitively intact resident with a documented care plan and physician’s order not to be awakened between 11 p.m. and 7 a.m. was disturbed when an RN entered the room while the resident slept and pulled down the covers to check a colostomy bag, and additional TAR orders were scheduled during the no-disturbance period, requiring staff to wake the resident despite the clearly stated preference.
Two residents experienced failures in care and protection when an assigned GNA did not provide any ADL care to a fully dependent, incontinent resident for an entire shift, despite documentation indicating care had been provided, and an RT behaved loudly and aggressively toward a ventilator‑dependent resident, making threatening statements about tying the resident down and "hitting back." An LPN on the ventilator unit, though familiar with the abuse policy, delayed reporting concerns about the RT’s conduct to management, and the incident was not reported to the state agency until several hours after the aggressive behavior began.
A contracted respiratory therapist allegedly intimidated a resident by stating that if a patient hit him, he would hit back, while the resident was agitated and raising hands in a blocking manner. A GNA later heard a loud smack from the room and, upon questioning, was told by an LPN that the therapist had not hit the resident but had clapped near the resident’s ears. Both the GNA and LPN felt uncomfortable but did not immediately remove the therapist from patient care, despite the LPN’s knowledge of the abuse policy and the unit’s ventilator status. Concerns were not promptly reported to the unit manager or DON, resulting in a failure to ensure resident safety by immediately removing the alleged perpetrator from patient care following an abuse allegation.
A resident received a double dose of oxybutynin ER over an extended period due to a medication order error that was not reported or corrected when first identified. A nephrology NP consultant documented that the resident was on a duplicate oxybutynin dose and recommended monitoring for LUTS while not recommending continuation of that drug, but did not notify facility staff or follow up, instead only uploading the consult into the EHR days later. The DON later learned that the NP had chosen not to report the error because she did not want to get anyone in trouble, resulting in the medication error remaining unaddressed.
Physicians and NPs did not consistently enter and upload progress notes and orders at the time residents were seen, resulting in delays and failures in implementing treatment plans. A resident admitted after a fall with rib fractures had a nephrology NP consult that was uploaded days after the visit, and the DON confirmed that nephrology consults and recommendations were not being promptly communicated. The facility NP stated she does not review the MAR and was unaware of the nephrology consult, so a medication error went unidentified until raised by a surveyor. For the same resident, an attending physician’s H&P note, including medication reconciliation and new orders for Oxybutynin discontinuation and Trospium initiation, was completed and uploaded many hours after it was started and the orders were never implemented, leaving the resident on duplicate Oxybutynin. Another resident’s physician note was dated as if the resident had been seen two days before the note was actually created, delaying staff access to any new orders, and the DON reported that multiple physician notes from prior months were also uploaded several days after completion.
The facility failed to ensure GNAs were competent in providing care, as shown by two incidents and missing competency documentation. In one case, a resident who required moderate assistance for toileting per the care plan was left alone on the toilet by a GNA, leading to a bathroom fall after the resident attempted to self-transfer. In another case, a resident with a broken leg reported pain after being transferred by a GNA, who described providing contact guard support by holding the resident’s ankles and later lifting the resident’s legs off the bed, prompting the resident to cry out in pain. Review of both GNAs’ files revealed no evidence of required skills checklists, annual evaluations, or training records, and leadership acknowledged concerns about the lack of training and education.
A resident admitted after a fall with rib fractures and with overactive bladder and BPH was given duplicate oxybutynin ER therapy when staff followed two concurrent orders for 10 mg and 5 mg (2 tabs) every morning, resulting in a total daily dose of 20 mg instead of the single 10 mg dose documented on hospital discharge records and physician notes. The MAR showed both orders were administered over multiple days. A nephrology NP documented the duplicate dosing in a consultation note she uploaded herself but did not notify facility staff, and the DON reported that consultations were expected to be routed through the unit manager or ADON for review and entry.
Facility administration failed to maintain proper oversight and documentation for a nephrology NP consultant, allowing consultations on residents without a timely-uploaded record, without a pre-existing contract, and without alignment between the DON and medical director on when and how the NP should be used. Leadership did not maintain or review a current facility assessment, so needed staff competencies were not defined, and orientation materials omitted required behavioral health content. Multiple clinical and non-clinical staff, including GNAs, an LPN, an RN, an activity assistant, and a laundry aide, had not completed required annual trainings, and the infection control module lacked facility-specific policies. Nurse aide files lacked annual performance evaluations and evidence of 12 hours of competency-based training, and the nurse aide training program consisted only of generic computer modules, with no structured competency validation or educator consistently overseeing completion.
The facility failed to implement an effective process for communication between the governing body and the administrator, including how, how often, and what information should be communicated. The written governing body policy lacked an implementation date and, although it required members to be active, engaged, and involved in facility affairs with direct access to the administrator and compliance officer and participation in QAPI, there was no evidence that governing body members attended QAPI meetings. Documentation identified the administrator as the Compliance and Ethics Officer and the DON, social worker, and medical director as members of the Compliance and Ethics Committee, but QAPI sign-in sheets did not show governing body participation. The NHA reported being unaware of a policy on governing body involvement, confirmed that the governing body had not attended QAPI meetings, and stated that she had not contacted them since her return to the facility.
Facility leadership failed to complete and maintain a comprehensive facility-wide assessment of needed resources for competent resident care. When surveyors requested the assessment, the NHA initially could not locate it and later produced an incomplete “Facility Assessment Tool” that was dated earlier and listed multiple signatories. The NHA acknowledged she had not reviewed or developed a facility assessment since returning to her role, and also reported having had no contact with the governing body during that time, despite the assessment indicating governing body involvement. The deficiency is cross-referenced to F835 and F940.
Facility staff did not ensure that an Infection Preventionist (IP) participated in QAPI committee meetings as required. Review of QAPI meeting sign-in sheets over a 10‑month period showed that an IP did not attend at least quarterly, with half of the reviewed meetings lacking IP attendance. A corporate clinical resource nurse, serving as the acting QA coordinator and IP, reported that no staff member had been formally assigned as an IP during this time frame, resulting in the QAPI group not having all required members.
The facility did not conduct comprehensive investigations into two separate allegations of abuse and neglect. In one instance, a resident with cognitive and physical impairments reported rough care by a GNA, but the investigation lacked interviews about prior behaviors and did not assess if other residents felt unsafe. In another case, after a neglect allegation, only residents able to communicate were interviewed, and non-verbal residents under the same staff member's care were not assessed, leaving the investigation incomplete.
Surveyors identified that multiple residents who required assistance with ADLs, including incontinence care and showers, did not receive the necessary personal care as documented in their records. One resident was left soiled for hours, another received far fewer showers than scheduled, and a third had multiple shifts with no documentation of care provided. Staff interviews confirmed gaps in care and documentation, and discrepancies were found between paper and electronic schedules.
A resident was transferred to the hospital for shortness of breath after experiencing a change in condition. Documentation by an LPN indicated that PRN oxygen was administered, but review of the medical record found no physician's order for the oxygen use. The DON confirmed that no order was entered into the resident's record.
Staff with facial hair, including a dietary aide, the kitchen manager, and the corporate Certified Dietary Manager, were observed preparing and handling food in the kitchen without wearing beard restraints as required by professional standards. The deficiency was acknowledged by the Nursing Home Administrator and the involved staff when brought to their attention.
A binder intended to display the most recent federal survey results was missing these documents, and staff were unaware of the omission until it was pointed out during a survey. The only location for survey results in the facility did not contain the required information, as confirmed by the DON and Regional Nurse Consultant.
A resident who was cognitively intact and responsible for their own medical decisions was not provided with information or opportunities to formulate an advance directive. Review of the medical record and interviews with the Social Services Director confirmed that no documentation or materials regarding advance directives were offered or discussed with the resident.
A resident experienced theft of personal items and cash after the lock on their bedside cabinet remained broken for one to two months, despite repeated reports to nursing staff. The unsecured drawer was observed open with valuables inside, and the resident was unable to secure their belongings. The DON acknowledged the failure to protect the resident's property and the lack of support for filing a grievance.
A resident reported missing hearing aids, but staff failed to initiate or follow the facility's grievance process. The grievance policy lacked identification of a Grievance Official, and staff were unclear about their roles in handling grievances. Although the grievance log showed the issue as resolved, the resident continued to report the hearing aids as missing, and key staff were unaware of the complaint or its resolution.
A resident received multiple doses of PRN Ativan without documentation of attempted non-pharmacological interventions or adequate behavioral indications for use. Nursing staff did not record required information in the eMAR or other available documentation systems, despite clear expectations for such documentation.
A resident with moderate cognitive impairment was transferred to a hospital, but there was no documentation that the resident's representative received written notification of the facility's bed hold policy or a transfer notice. Staff interviews confirmed uncertainty or lack of documentation regarding the process for providing these required notifications.
A resident's MDS assessment inaccurately documented insulin injections for seven days, despite no supporting diagnosis, orders, or evidence of injections in the medical record. The MDS nurse, who relied on the MAR for information, was unable to provide documentation to support the recorded insulin use and acknowledged the error after review.
A resident with schizoaffective disorder and developmental delay was admitted without completion of a required PASARR Level II evaluation. Record review and staff interview confirmed that neither a Level II review nor an exemption was documented, despite care planning for mental health and developmental conditions. The deficiency was acknowledged by facility staff during the survey.
Surveyors found that two residents did not have individualized care plans reflecting their assessed needs and preferences. One resident's care plan lacked details about preferred activities, pet visits, and outdoor time, and did not include current orders or documentation for pressure ulcer prevention equipment. Another resident's care plan omitted preferences for outdoor and religious activities and failed to address ongoing bilateral leg edema, despite staff awareness of these issues.
Two residents did not receive individualized or consistent activity programming in accordance with their assessed needs and preferences. One resident with cognitive impairment had a care plan lacking specific activities and documentation, with many days showing no activity participation. Another resident with dementia and hearing loss was left without meaningful engagement, and activity logs did not reflect their preferences for outdoor time or religious services.
A resident with significant hearing and vision impairment was not assisted in obtaining necessary hearing aid repairs, despite staff awareness of the issue. The hearing aid remained nonfunctional and unused, and staff interviews revealed a lack of communication and follow-through to address the resident's needs.
A resident with significant cognitive impairment and a stage 4 pressure ulcer did not consistently receive wound care as ordered due to errors in entering wound care orders, missed documentation of dressing changes, and incorrect air mattress settings. Staff failed to ensure the air mattress was set according to the resident's weight and did not maintain required documentation or current orders for its use, resulting in lapses in pressure ulcer prevention and care.
A bottle of toilet bowl cleaner containing bleach was found stored under the sink in a nourishment pantry secured by keypad entry. An LPN and the unit manager present at the time acknowledged the chemical should not have been stored there, indicating a failure to ensure safe and appropriate storage of toxic chemicals.
Surveyors found that annual performance evaluations were not completed for two GNAs, as only one evaluation was provided when requested. The Administrator confirmed the absence of required evaluations, and no further documentation was submitted before the survey ended.
A facility failed to accurately reconcile and document controlled medications, as required by policy. An RN inaccurately signed for both on-coming and off-going shifts during narcotic counts, and this error was confirmed by a unit manager. The DON acknowledged that the facility's narcotic reconciliation practices did not meet acceptable standards.
The facility failed to ensure timely communication and documentation of pharmacy recommendations during monthly medication regimen reviews for two residents. In one case, a pharmacist's report was sent late and another was missing from the medical record, while in another case, there was no documentation of provider review or action taken in response to pharmacy recommendations. The DON confirmed these lapses in the medication management process.
A resident with hypertension received blood pressure medication outside of prescribed parameters, as the medication was administered even when the systolic blood pressure was below the threshold specified in the medical orders. The DON confirmed that the medication was given inappropriately on multiple occasions, as documented in the eMAR.
Surveyors found expired lubrication jelly in the emergency cart and unattended diabetic lancets on a medication cart, both confirmed by nursing staff as improper. Additionally, all medication refrigerators lacked properly secured narcotic lock boxes, with some missing or broken, and maintenance staff were unaware of repair needs, contrary to facility policy.
A resident with documented dental issues reported never receiving dental care, despite being enrolled in a dental program and having monthly premiums deducted from their personal funds. The DON stated the resident refused services, but there was no documentation to support this, and the resident denied refusing care.
Surveyors identified that two residents had discrepancies between their MOLST forms and the corresponding physician orders in the EHR. In one case, a resident's MOLST allowed intubation while the EHR order did not, and in another, a resident's MOLST prohibited hospital transfer while the EHR order permitted it for unmanaged symptoms. These mismatches were confirmed by staff during the survey.
Staff did not consistently follow infection prevention and control protocols, including Enhanced Barrier Precautions and hand hygiene, for three residents with indwelling devices or infections. Lapses included not donning required PPE during high-contact care, failing to perform hand hygiene before and after glove use, and improper disposal of contaminated materials. These actions were acknowledged by the involved staff and unit managers.
A review of employee files found that several staff members did not have documentation showing they were offered the current COVID-19 vaccine or that they accepted or refused it. This was confirmed by both the regional Nurse Consultant and the DON, with one staff member no longer employed and no declination available for that individual.
A resident identified as an elopement risk, who required a WanderGuard device on their wheelchair, was observed unattended in the main entrance lobby. When the WanderGuard alarm was triggered during a demonstration, the doors did not close or lock as required, and staff were unaware of how to properly assess the system's function. The DON confirmed that elopement risk residents should be supervised and was not aware of the malfunction, resulting in a failure to maintain the safe operation of the WanderGuard exit system.
The facility did not promptly notify the attending provider, responsible party, or registered dietitian when a resident experienced significant weight loss while on tube feeding, and also delayed notification after another resident's fall and change in condition. Documentation and communication lapses led to delays in addressing these significant changes, contrary to facility policy.
A resident with severely impaired cognition did not consistently receive the necessary assistance with meals, as required by their assessment. Review of GNA ADL documentation showed multiple shifts over several months where meal assistance was not documented, and this lack of documentation was confirmed by the DON.
A resident with a history of hip surgery did not receive effective pain management, as staff failed to document pain assessments and the use of non-pharmacological interventions before administering PRN opioid medication. Additionally, there was no record of further pain management actions when the resident continued to experience pain after medication, contrary to provider orders and DON expectations.
Failure to Identify and Repair Environmental Damage in Resident Rooms
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by environmental deficiencies in two resident rooms on a specified unit. During a complaint survey assessing rooms affected by a faulty sprinkler system, the surveyor observed a water-stained ceiling tile in one resident room and damaged drywall behind Bed B in another resident room. The Maintenance Director reported that resident rooms are checked through weekly and monthly audits and that staff are expected to submit work orders in the TELS system for maintenance concerns, but no work orders had been received regarding the stained ceiling tile or the damaged drywall. The DON also stated they did not think a work order had been submitted for these issues. A GNA reported not noticing the damaged drywall in the affected room, and an RN stated they did not pay attention to maintenance concerns during their morning rounds, indicating that staff did not identify or report the observed environmental damage. These observations and interviews show that despite existing audit routines and reliance on staff-generated work orders, the stained ceiling tile and damaged drywall in the residents’ rooms were not recognized or reported by nursing or maintenance staff, resulting in the continued presence of these environmental deficiencies in occupied resident rooms.
Failure to Clarify and Complete IV Fluid Order
Penalty
Summary
Facility staff failed to clarify and accurately implement an IV fluid order for a resident treated for dehydration. Record review showed that on 02/11/26 at 10:57 a.m., the resident was ordered Lactated Ringers 1 liter IV at 75 ml/hour for 2 days. The medication administration record indicated the fluids were signed off as given on 02/11/26 and 02/12/26, but there was no documentation verifying that IV fluids were administered on 02/13/26. During interview, the DON stated the resident was supposed to receive 2 liters in 24 hours and then 1 liter the following day, and that the whole order was intended to cover 2 days, with 2 liters the first day and 1 liter the second day. The DON acknowledged the order was poorly written and confusing, and that staff did not clarify the order. A progress note written by the NP on 02/11/26 at 12:07 p.m. documented that the resident was started on Lactated Ringers IV at 75 cc/hour for 2 liters on 02/11/26 and that IV fluids were to continue for 48 hours. In a subsequent interview, the NP stated they were uncertain how the order was transcribed and, when informed that their note indicated IV fluids for 48 hours beginning on 02/11/26, the NP stated that this note was a typo and that when the nurse started a new bag of IV fluids, a new order was written in error. These discrepancies and lack of clarification resulted in the resident not receiving the full course of IV fluids as ordered.
Failure to Initiate Timely Wound Assessment and Treatment for Multiple Foot Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple left foot wounds received timely and appropriate wound care and treatment upon admission. The hospital discharge summary documented talar osteomyelitis of the left foot, with wound care having applied a dry sterile dressing and kerlix and a plan to consult the resident’s podiatrist, but did not list any additional wounds or specific treatment orders. On admission, the facility’s nursing admission note identified a scab on the left ankle, a sore on the left foot, and a sore on the left heel. Despite these findings, there were no corresponding wound treatment orders in the medical record. The attending physician completed a history and physical on the day of admission, repeating the hospital’s osteomyelitis note, documenting no rashes, lesions, or nodules on skin exam, and not mentioning the additional wounds identified by nursing or initiating any wound treatment orders. Wound care notes showed that the wound nurse practitioner did not first see the resident until 10 days after admission, at which time the resident was found to have a venous ulcer on the left medial malleolus, a left plantar diabetic foot ulcer, and an unstageable pressure ulcer on the left heel, and treatment was then started. The attending physician later stated that he had not assessed the resident’s left foot wounds or provided treatment orders because a wound specialist manages wounds and that he did not have time to see the resident for wound care. The DON stated that the admitting nurse should have read the discharge instructions, clarified the wound order mentioned, and notified the physician to obtain orders for the other two wounds identified on admission. The surveyor was unable to interview the admitting LPN, who had been terminated due to concerns with nursing care.
Failure to Identify and Manage Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify a cognitively impaired resident as an elopement risk and to implement interventions to prevent elopement, resulting in the resident leaving the building unsupervised. The facility had an elopement and wandering policy requiring residents to be assessed for elopement risk on admission and throughout their stay, with high‑risk residents to receive an alarm bracelet and an individualized care plan. On admission, the nursing elopement assessment for this resident was completed by an LPN, who marked the resident as unable to ambulate; this locked the remainder of the elopement assessment and resulted in the resident being deemed not at risk for elopement. This determination was made despite hospital records showing that prior to admission the resident had been living at home, driving, and working, and that during the hospital stay the resident could ambulate with a rolling walker and assistance. Following admission, multiple clinical findings and events indicated that the resident’s condition and behavior had changed in ways relevant to elopement risk, but the facility did not reassess the resident for elopement until after the elopement occurred. Progress notes documented that the resident fell twice in the early morning of one day when attempting to get out of bed and walk, with staff noting the resident was unsteady. A care plan was initiated for noncompliance with using a walker. A Brief Interview for Mental Status determined the resident had severe cognitive impairment, and both the attending physician and a nurse practitioner documented that the resident was incapable of comprehending information and making decisions due to a hemorrhagic stroke. Therapy notes showed that the resident’s mobility improved, including ambulating 70 feet with a rolling walker and minimal assistance, which constituted a change in condition. Staff interviews later revealed that the resident frequently talked about going home, became more worked up when family prepared to leave, walked unassisted despite being unsteady, wandered without clear purpose, and had poor safety awareness. On the day of the elopement, the resident was observed by the receptionist walking down the hallway carrying a wash basin with items and a shoebox, then exiting through the front door; the receptionist was unsure if the individual was a resident and did not intervene before the resident left the building. The resident’s assigned LPN and GNA reported they were passing dinner trays and checking blood sugars and did not see the resident leave the unit. A visitor arriving for a Thanksgiving event later found the resident lying on the ground in the visitor parking lot in dark, cold weather, still carrying the basin and shoebox. Another LPN leaving the facility also saw the resident on the ground behind a parked car and initially did not recognize the person as a resident until noticing an adult brief. When interviewed, the resident stated they had gone outside to go home. The facility’s own investigation concluded that the resident left the facility, was outside for several minutes, and was found lying in the parking lot, and that staff had not previously identified or care planned the resident as an elopement risk despite documented behaviors and functional abilities that met the facility’s own criteria for elopement risk. The facility’s investigation file also showed that, prior to the incident, staff education on the elopement policy and elopement assessments had been started but not completed for all staff. Interviews with the interim DON and other staff confirmed that elopement assessments were expected on admission, quarterly, and with changes in condition or behavior, and that the resident’s behaviors—such as repeatedly talking about going home, packing belongings, and exit‑seeking—should have triggered reassessment. The NHA acknowledged that the resident was not being monitored as an elopement risk because the admission assessment had categorized the resident as not at risk, even though the NHA identified behaviors like wanting to go home and packing belongings as high‑risk indicators. These combined assessment failures, lack of reassessment after clear changes in condition and behavior, and lack of effective supervision and response to observed exit‑seeking behavior led to the resident’s elopement and subsequent fall in the parking lot, where the resident sustained an abrasion to the right side of the face and scrapes on both hands.
Removal Plan
- Resident #6 no longer resides in the facility.
- Complete updated elopement evaluations for all current residents to determine if any residents are at risk for elopement.
- Complete updated elopement evaluations by the Unit Managers and DON.
- Recheck alarm bracelets for proper placement and function for all residents determined to be at risk for elopement.
- Place any resident identified at increased risk for elopement on appropriate elopement precautions and update the care plan.
- Educate all facility licensed staff on the elopement policy and procedure, including the elopement risk evaluation process, to ensure elopement risk is reassessed.
- Educate all licensed nurses.
- Educate any licensed staff member unable to attend scheduled education upon arrival to the facility, and ensure education is provided prior to beginning their shift.
- Continue to educate all non-clinical staff on elopement policy and procedures, including identifying elopement risk signs and symptoms and reporting to appropriate clinical staff.
- Educate any facility staff member unable to attend scheduled education upon arrival at the facility, and ensure education is provided prior to beginning their shift.
- Validate education by administering quizzes randomly with 10% of staff weekly.
- Conduct audits monthly.
- Report findings at the monthly QAPI meeting to monitor progress towards improvement and recommendations.
Lack of Annual Performance Evaluations for Nurse Aides
Penalty
Summary
Facility staff failed to ensure that geriatric nursing assistants (GNAs) received annual performance evaluations of their skills, as required to identify weaknesses and provide targeted training. Record review on 1/22/26 showed that GNA #37, hired in 11/2018, had no documented performance evaluation within the last 12 months. Similarly, GNA #14, hired in 2/2019, and GNA #36, hired in 4/2023, also had no evidence of a performance evaluation in the preceding year. In an interview on 1/22/26 at 12:21 PM, the DON and NHA acknowledged that the facility had no process in place to ensure that nurse aides received annual performance evaluations. This deficiency was cross-referenced to F947, indicating it related to training and competency requirements for staff.
Unauthorized Nephrology Consultations Without Orders or Contract Oversight
Penalty
Summary
Facility administration allowed a nephrology nurse practitioner (NP #13) to provide consultation services to residents without an established contract in place and without physician orders authorizing these consultations, contrary to facility policy. For Resident #16, a nephrology consult was completed on 1/13/26 and not uploaded until 1/15/26, and there was no physician order for this resident to be seen by a nephrologist or consultant. Within that consult, NP #13 documented a medication error on the resident’s medication administration record but did not notify facility staff; the error was instead brought to the DON’s attention by the survey team on 1/21/26, eight days after NP #13 identified it. The facility’s policy on Provision of Physician Ordered Services, revised 2/18/25, states that no diagnostic tests or consultation requests will be performed without specific orders from a physician, PA, NP, or CNS in accordance with state law. Further record review of four additional randomly selected residents showed that all had been seen by the same nephrology NP consultant beginning around 11/9/25, with consultation notes uploaded days after the visits and no corresponding physician orders for nephrology consultations. NP #13 was reportedly seeing every new admission based on lists provided by unit managers when she arrived. The facility medical director stated that the process for nephrology consultation should involve residents with a diagnosed need and an order from their attending physician, and acknowledged that the contract for this consultant was not signed until 1/27/26, despite her seeing residents since at least November 2025. He also stated that he was not the resource following up on NP #13’s consultations and that this should be an actual nephrologist, and there was no nephrologist signing off on NP #13’s consultations.
Failure to Maintain Effective Staff Training Program and Ensure Completion of Required Education
Penalty
Summary
Facility staff failed to develop and implement an effective training program for new and existing staff, contracted staff, and volunteers, as required by regulation and based on the facility assessment. Review of the facility’s orientation PowerPoint on 1/22/26 showed that behavioral health topics were not included, despite the requirement that such topics be based on the behavioral health needs identified in the facility assessment for the resident population. Although the list of computer-based training modules included required topics such as effective communication, Resident Rights, Elder Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. During interview, the NHA reported she did not have a copy of the previous NHA’s facility assessment and had not completed a new assessment since returning to the position in 8/2025, resulting in training topics not being aligned with the facility’s assessed needs. Review of individual staff computer-based training transcripts on 1/22/26 showed multiple staff members were not current with required trainings. One GNA had completed only four computerized training modules in 2024, with abuse being the only required topic listed, and had no completed trainings between 2021 and those 2024 modules. An LPN had last completed computerized training modules in 2022, and two other GNAs had not completed computerized training modules since 2024. A laundry aide had not completed Resident Rights training since 2023 and had not completed infection control training that included the facility’s policies and procedures. The Corporate Clinical Resource Nurse, who had served as interim DON and was acting as Nurse Practice Educator, stated that corporate determined and assigned annual computer-based training topics, but the facility had no system to ensure staff actually completed the assigned modules. When these concerns were reviewed with the NHA, she offered no rationale for the deficient practice.
Failure to Implement Required Annual Nurse Aide Training and Competency Program
Penalty
Summary
Facility staff failed to develop and implement a nurse aide training program that ensured each nurse aide received 12 hours of annual training, including competencies and education in dementia care and abuse prevention, and that training addressed weaknesses identified during annual performance evaluations. Record review on 1/22/26 showed that the personnel file for GNA #37, hired in 11/2018, contained no evidence of a performance evaluation or 12 hours of training with competencies in the last 12 months. Similarly, the file for GNA #14, hired in 2/2019, and the file for GNA #36, hired in 4/2023, lacked documentation of a performance evaluation or 12 hours of competency-based training in the last 12 months. Review of computer-based training transcripts for these three GNAs also failed to show completion of 12 hours of training with competencies in the last 12 months. On 1/16/26, review of the facility’s nurse aide training program/plan revealed it consisted only of a list of computer-based training modules and did not include skills competencies. The NHA and Corporate Clinical Resource Nurse Staff #3 confirmed that this list was their nurse aide training program, and the acting Nurse Practice Educator (Staff #13) stated that the facility had not developed and implemented a training program for nurse aides. These findings were cross-referenced with F730.
Failure to Timely Report Allegations of Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse, neglect, and injuries of unknown origin to the State Agency (SA) within required timeframes after staff became aware of them. For one incident, a resident reported to a GNA that someone had been in the room and touched the resident inappropriately at 6:45 AM. The on‑call Unit Manager acknowledged being aware of the allegation before 9:30 AM but did not notify the Nursing Home Administrator (NHA) until 9:30 AM, and the report to the SA was not sent until 10:47 AM. The NHA, who was involved in abuse investigations and review of final reports, could not explain the discrepancy between the time the allegation was known and the time it was reported to the SA. In another incident, an injury of unknown origin involving discoloration and bruising to a resident’s right knee and shin was known to staff earlier than what was reported to the SA. A family member reported a bruise on the resident’s right knee on one evening, and an RN documented this in the progress notes the following day, which would have required reporting to the SA within 24 hours. However, the facility’s investigation file indicated that management did not recognize the injury of unknown origin until two days later in the morning, and the SA was not notified until late that morning. The RN involved stated she knew injuries of unknown origin should be reported to the NP and supervisor and that suspected abuse should be reported to the NHA within 2 hours, but she had no rationale for not reporting this injury when first made aware. The Corporate Clinical Resource Nurse confirmed the RN’s earlier awareness, and the NHA again could not explain the discrepancy in the reported awareness time. Additional deficiencies occurred when staff failed to promptly report allegations of abuse and improper care involving other residents. In one case, a respiratory therapist was documented as having loud, aggressive interactions with a ventilator‑dependent resident, including statements about tying the resident down or sending the resident out, and a statement that patients who hit the therapist would be hit back. A GNA described the resident as anxious with arms up blocking the therapist, and the LPN on the unit acknowledged knowing the abuse policy and recognizing the behavior as inappropriate but only texted the unit manager hours later; the facility did not report the allegation to the SA until approximately five hours after the start of the therapist’s documented aggression. In another case, a resident reported pain and an inappropriate transfer by a GNA during a move to a bedside commode, and the resident’s daughter later called to reiterate the resident’s pain and allegation. Although the GNA was reassigned and management was notified, no further action was taken until two days later when the resident continued to voice concerns and left AMA, and the SA was not notified of the allegation until that same day, well beyond the required reporting timeframe. The NHA acknowledged understanding that this reporting was late.
Failure to Honor Resident Dignity, ADL Needs, and Nighttime Preferences
Penalty
Summary
Facility staff failed to honor residents’ rights to dignity and self-determination by not addressing one resident’s ADL needs in a timely manner and by disregarding another resident’s clearly documented preference not to be disturbed during specified nighttime hours. During a unit tour, a resident later identified as Resident #7 was observed at the nurses’ station repeatedly and loudly requesting assistance to use the bathroom, stating they had stomach pain and did not want to soil themselves. An LPN at the nurses’ station verbally acknowledged that the resident needed a lift and should not stand, but then continued medication preparation and administration, later walking around the station and sitting at the desk on the phone without providing assistance, attempting to soothe the resident, or arranging for timely toileting. The observations showed that Resident #7 continued to call out for help for an extended period, from at least 11:03 AM until 11:15 AM, with visitors also present and concerned, while the LPN did not respond to the resident’s expressed need for toileting and relief of stomach pain. The resident’s care plan included that the resident was known to fixate on going to the bathroom and might sit on the commode without voiding, but the DON acknowledged that this did not excuse the lack of response from the nurse on the day of observation. ADL care was eventually provided at 11:24 AM by another staff member, an RN working in the role of a GNA, who took the resident to their room and placed them on the toilet, indicating a significant delay between the resident’s initial requests and the provision of toileting assistance. In a separate incident, the facility did not respect Resident #4’s documented preference and physician’s order not to be awakened between 11:00 PM and 7:00 AM. The resident had no cognitive impairment per a quarterly MDS and was able to voice needs, and the care plan and a physician’s order both specified that the resident was not to be woken during those hours. Despite this, an RN entered the resident’s room around 6:15 AM while the resident was asleep, pulled down the covers, and inspected the resident’s colostomy bag. Additionally, the Treatment Administration Record contained staff-entered orders scheduled between 11:00 PM and 7:00 AM, including turning and repositioning, catheter care, and administration of fluids, which required staff to wake the resident during the period they had expressly requested and been ordered not to be disturbed. The resident reported wanting staff to empty the colostomy bag before bedtime and stated being fully capable of requesting help when needed, and the unit manager confirmed awareness of the resident’s preference not to be awakened at night.
Failure to Provide ADL Care and Protect Residents From Intimidation and Abuse
Penalty
Summary
A staff member failed to provide required care and maintain respect and dignity for a dependent resident when a GNA assigned to Resident #10 did not provide any activities of daily living (ADL) care for an entire shift. The facility’s investigation documented that the GNA admitted he did not provide care all day, stating he believed the resident was a “no male” caregiver case, despite having signed off in documentation as providing ADL care to this resident on the previous day and earlier in the month. The resident’s MDS, completed shortly after the incident and reflecting the look‑back period that included the date of the allegation, showed the resident was dependent on staff for all ADLs, frequently incontinent of bladder, and always incontinent of bowel. The LPN assigned to the resident that day reported the resident never complained and that she did not notice the resident soiled, even though the MAR showed she had signed for applying powders and creams to multiple body areas that would have required assessment and recognition of any incontinence needing care. Another deficiency involved failure to protect a resident from intimidation and potential abuse by a respiratory therapist (RT). The RT documented that a ventilator‑dependent resident was repeatedly disconnecting from the ventilator and described the resident as combative, suggesting the resident be sent to the hospital if restraints were not used. A GNA present during the interaction reported that the RT was loudly and aggressively demanding help and stated that if the resident was not tied down, the resident would be sent out, and further reported that the RT told the resident that his patients know not to hit him because he hits back. The LPN caring for the resident acknowledged familiarity with the abuse policy and stated she knew the RT should have left but felt stuck due to working on a ventilator unit. She reported that she first texted her unit manager about the RT’s behavior later that afternoon and received only a brief response, and that she did not escalate the concern until the end of the shift, by which time the RT had gone home. The facility officially reported the incident to the state agency several hours after the onset of the RT’s documented aggressive behavior toward the resident.
Failure to Remove Alleged Abusive Respiratory Therapist From Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety by immediately removing an employee from patient care following an allegation of abuse or intimidation. A contracted respiratory therapist was alleged to have intimidated a resident by stating, in the presence of multiple staff, "I tell you like I tell all my patients, if you hit me, I hit back." A GNA reported that the resident was agitated and raising hands in a blocking manner, not attempting to hit the therapist, and that the therapist had been loud and agitated throughout the day. The GNA was upset by the incident and believed the nurse had reported the therapist. After the GNA left the room and was in the hall, she heard a loud “smack” sound; when the nurse exited the room, the GNA asked if the therapist had hit the resident, and the nurse responded that he had not, but had “clapped at [resident] ears.” The LPN caring for the resident recalled discussing the situation with the GNA and stated that both were uncomfortable but felt “stuck” because the therapist was the only respiratory therapist available on a ventilator unit. The LPN acknowledged familiarity with the abuse policy and that the therapist should have been removed from patient care but did not do so. According to interview statements, the unit manager documented first being notified of concerns about the therapist at 6:28 PM, which differed from the LPN’s account of earlier notification, and the DON was not notified of the concerns until a later date. The facility’s failure to immediately remove the therapist from resident care upon the allegation of abuse/intimidation and the delay in reporting up the chain of command led to the cited deficiency.
Unreported Oxybutynin Dosing Error Identified but Not Acted Upon
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when a medication error involving oxybutynin was not reported or acted upon after it was identified. Medical record review of one resident’s MAR showed that the resident had been ordered and receiving a double dose of oxybutynin chloride ER, 20 mg instead of the intended 10 mg, from 1/9/26 until the date of review on 1/21/26. Oxybutynin is identified in the report as an anticholinergic medication used to treat overactive bladder, with overdose symptoms that may include central nervous system overactivity, rapid heartbeat, high blood pressure, anxiety, headaches, fever, cardiac arrhythmia, vomiting, respiratory failure, paralysis, and coma. Further review of the resident’s medical record showed that a nephrology NP consultant completed a consultation on 1/13/26 and documented that the resident was receiving a duplicate dose of oxybutynin. In that consultation, the NP did not recommend continuation of oxybutynin, unlike two other urinary medications, and recommended monitoring for lower urinary tract symptoms (LUTS). However, the NP did not report the medication error to facility staff, did not follow up on the issue, and only uploaded the consult into the EHR on 1/15/26, two days after completion. In an interview, the DON stated that when she later questioned the NP about why the error had not been brought to anyone’s attention, the NP said she did not want to get anyone in trouble. These actions and inactions resulted in the medication error going unreported and unaddressed for an extended period.
Untimely Physician Documentation and Failure to Implement Treatment Orders
Penalty
Summary
Physicians and NPs failed to complete and upload progress notes and orders to the medical record in a timely manner and did not ensure that care plans and treatment orders were fully reviewed and implemented. For one resident admitted after a fall with rib fractures, a nephrology NP consultation performed on 1/13/26 was not uploaded and available to staff until 1/15/26, and the DON confirmed that this consultant had been uploading her own reports days after seeing residents, with recommendations not being communicated. The unit manager described a new process in which the nephrologist enters their own orders and uploads their own consults, and also stated that the facility had not been receiving anything directly from nephrology for about two months. The facility NP reported that she does not review the MAR, was unaware that the resident had a nephrology consult, and therefore did not identify a medication error until it was brought to the DON’s attention by the surveyor. For the same resident, the attending physician began a history and physical note on 1/12/26 but did not complete and sign it until 1/13/26, making it available about 36 hours after initiation. That note documented reconciliation of medications and included an order to discontinue a 10 mg dose of Oxybutynin while continuing two 5 mg tablets, and to start Trospium for overactive bladder; however, these changes were not implemented, and the resident continued on a duplicate Oxybutynin dose until 1/21/26. For another resident, the attending physician entered an effective date indicating the resident was seen on 1/12/26, but the note was not created and available in the record until 1/14/26, delaying access to any associated orders. The DON acknowledged that there were multiple physician notes from prior months that were uploaded days after completion and that the attending physician involved no longer worked at the facility.
Failure to Ensure GNA Competency in Resident Transfers and Toileting
Penalty
Summary
The deficiency involves the facility’s failure to ensure that GNAs possessed and demonstrated appropriate competencies for safe resident care, as evidenced by two resident incidents and missing competency documentation. In the first case, a resident who, according to the care plan, required moderate assistance of one staff member for toileting was left alone on the toilet by the assigned GNA. The resident attempted to transfer independently from the toilet and fell in the bathroom, which was the second fall within a week while attempting to use the toilet. The facility’s fall investigation, reviewed with the DON, confirmed that the GNA did not follow the resident’s care plan by failing to remain with and appropriately transfer the resident. Review of this GNA’s employee file showed no annual evaluations of skill sets or online training, and the acting Corporate Clinical Resource Nurse/NPE/IP/QA nurse stated she was not aware of where employee certificates were kept and did not provide additional documentation. In the second case, a facility-reported incident involved a resident with a broken left leg who complained of pain after being transferred by the assigned GNA. The resident reported pain to the nurse and stated they had been inappropriately transferred, and an investigation was not initiated until the resident’s daughter later called to report ongoing pain and the allegedly improper transfer to a bedside commode. During the facility’s investigation, the GNA reported that during the first transfer back to bed, she provided contact guard support by holding the resident’s ankles, and during a second transfer, she lifted the resident’s legs off the bed, at which point the resident began yelling that they were being hurt. Review of this GNA’s personnel file showed that, although she had been hired months earlier, there was no new-hire skills checklist or annual evaluation of GNA skills. The DON acknowledged concerns about the lack of training and education, and these concerns were presented to facility leadership during the survey.
Failure to Prevent Duplicate Oxybutynin Therapy
Penalty
Summary
Facility staff failed to ensure a resident’s drug regimen was free from unnecessary drugs by administering duplicate oxybutynin therapy over a sustained period. Medical record review showed that the resident was admitted after a fall with rib fractures for monitoring of routine healing and also had diagnoses of overactive bladder and benign prostatic hyperplasia. Review of the physician orders and MAR revealed two concurrent orders: Oxybutynin Chloride ER 5 mg (2 tablets) every morning for bladder spasms and Oxybutynin Chloride ER 10 mg every morning for urinary retention, both signed out by staff from 1/9/26 through 1/21/26. Review of the hospital discharge records and physician notes showed only a single intended order for Oxybutynin 10 mg daily, not a total of 20 mg per day. Further review of the resident’s medical record identified that a nephrology consultation completed at the facility by a consultant NP documented that the resident was receiving a duplicate dose of oxybutynin. The consultant NP uploaded her own consultation report with recommendations days after the visit. The DON stated that consultations should go to the unit manager or ADON for review and then be entered by them, and it was reviewed with the DON that the nephrology consultant was uploading her own reports. The DON later reported that the NP acknowledged identifying the medication error but did not bring it to anyone’s attention, stating she did not want to get anyone in trouble.
Deficient Administration of Consultant Services, Facility Assessment, and Staff Training
Penalty
Summary
Facility leadership failed to ensure appropriate conditions and oversight for a nephrology nurse practitioner (NP) consultant who had been seeing residents since November 9, 2025. At least five residents had nephrology consultations documented starting January 21, 2026, but the completed consultation notes were not uploaded into the medical record for several days, even when they contained recommendations or concerns. The DON reported that the NP would be seeing all new admissions and all residents with kidney disease, while the medical director stated that the consultant was not to see every new admission and that a physician order and an actual nephrologist following behind the NP were required. During the survey, it was identified that there had been no contract in place during the months the NP had been seeing residents, and the contract produced by the NHA was signed only the day before, demonstrating a lack of an established, consistent process for use of this consultant. The facility did not have an accessible, current facility-wide assessment to determine needed resources and staff competencies. When surveyors requested the facility assessment, the NHA was unable to locate it and had to request it from corporate, and she acknowledged she had not reviewed the assessment since assuming her role on August 25. As a result, the training and skill sets required for staff to care for the resident population had not been determined. Review of the orientation PowerPoint showed that required behavioral health training was not included, and personnel files for an LPN, an RN, an activity assistant, and multiple GNAs showed they were allowed to care for residents without having completed the required behavioral health training. Further review of the facility’s training program revealed that while computer-based modules existed for required topics such as effective communication, resident rights, elder abuse, QAPI, infection control, compliance and ethics, and behavioral health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. Training transcripts showed that several GNAs, an LPN, and a laundry aide had not completed required annual trainings or had significant gaps since prior years. The acting NPE stated that although a training process was in place, no one was ensuring timely completion, and these staff continued to work. Additionally, nurse aide files for multiple GNAs lacked evidence of annual performance evaluations and 12 hours of training with competencies in the last 12 months, and the nurse aide training program provided by the NHA consisted only of a list of computer-based modules without competency components. The acting NPE confirmed that the facility had not developed and implemented a nurse aide training program based on evaluations, and the NHA acknowledged there was no consistent person in the educator role.
Failure to Implement Effective Governing Body Communication and QAPI Involvement
Penalty
Summary
The facility failed to establish and implement a process for communication between the administrator and the governing body, including the mode of communication, frequency, and content of what was to be communicated. Review of the Governing Body Policy and Procedure showed no implementation date and stated that governing body members were to be active, engaged, involved in facility affairs, have direct access to the administrator and compliance officer through executive board sessions, and be involved in the QAPI program. A letter designated the administrator as the Compliance and Ethics Officer and identified the DON, social worker, and medical director as members of the Compliance and Ethics Committee. However, review of QAPI meeting sign-in sheets showed no evidence that any governing body member attended these meetings. In an interview, the NHA stated she was not aware of a policy regarding governing body involvement with the facility, reported that governing body members had not attended QAPI meetings, and acknowledged she had not contacted them since her return to the facility.
Failure to Complete and Accurately Document Required Facility Assessment
Penalty
Summary
Facility leadership failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. On 1/16/26 at 10:55 AM, the Nursing Home Administrator (NHA) was informed that an extended survey was being conducted and was asked to provide the Facility Assessment. During an interview later that day at 12:21 PM with the NHA and the Nurse Educator/Infection Preventionist, the NHA stated she was unable to locate the assessment and needed to request it from the corporate office. When asked if she had reviewed or developed a facility assessment since assuming the position in 8/2025, she reported that she had not. At 1:30 PM on the same day, the NHA provided a document titled “Facility Assessment Tool,” dated 1/5/26, which indicated it had been completed by the NHA, Medical Director, Governing Body representative, and others; however, review showed it was incomplete. In a subsequent interview at 1:46 PM, the NHA confirmed she had not reviewed or completed a facility assessment until the surveyor requested it on 1/16/26, initially explaining this by stating she started in the position in 8/2025, although it was later reported she had previously served as the facility’s NHA from 2020–2024. In a later interview on 1/20/26 at 3:17 PM, the NHA reported she had not been in contact with the governing body since returning in 8/2025, meaning she could not have obtained input from a governing body member as documented on the assessment provided to the survey team. Cross references were made to F835 and F940.
Failure to Ensure Infection Preventionist Participation in QAPI Meetings
Penalty
Summary
Facility staff failed to ensure that the Infection Preventionist (IP) was in attendance at the Quality Assurance and Performance Improvement (QAPI) committee meetings as required. Record review of QAPI committee meeting sign-in sheets for the period from March 2025 through December 2025 showed that an IP had not attended the meetings on at least a quarterly basis, with 5 of 10 meetings reviewed lacking IP attendance. During an interview, the Corporate Clinical Resource Nurse, who was acting as the Quality Assurance coordinator and IP, stated that the facility had not had a staff member formally assigned as an IP for the past 10 months. This lack of an assigned IP and the resulting failure to have the IP present at QAPI meetings led to noncompliance with the requirement that the Quality Assessment and Assurance group include the required members and meet at least quarterly with appropriate representation.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect involving two residents. In the first case, a resident with Alzheimer's disease, depressive disorder, and a femur fracture alleged that a GNA was rough during care, causing bleeding. Although the resident initially refused assessment, a later skin check showed no injury. The facility's internal investigation included interviews with some staff and residents, but did not document whether staff were asked about prior observations of rough or unprofessional behavior by the GNA, nor whether other residents felt unsafe or had experienced similar issues. The investigation was concluded as unsubstantiated without fully determining if other residents were at risk. In the second case, following an allegation of neglect by another resident against a staff member, the facility suspended the alleged perpetrator and interviewed some residents on the staff member's assignment who could communicate. However, the investigation did not include head-to-toe assessments of non-verbal residents who had also been under the care of the alleged perpetrator. The DON acknowledged that these residents, who could not speak for themselves, were not assessed as part of the investigation, resulting in an incomplete review of the potential neglect incident.
Failure to Provide and Document Required ADL Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were unable to perform these tasks independently. In one case, a resident who was totally dependent on staff for incontinence care was found soiled by EMTs and ER staff after being unable to obtain help for over two hours, as documented in both emergency medical records and the resident's own report. Review of the resident's medical record and ADL documentation revealed multiple shifts with no recorded incontinence care provided, and the interim DON confirmed the lack of documentation for the identified periods. Another resident, diagnosed with dementia and severe cognitive impairment, was scheduled to receive two showers per week but received only one shower per month over a four-month period, as shown by a review of the ADL documentation. Discrepancies were found between the paper shower schedules and the electronic health record, and staff confirmed that showers were not properly scheduled in the EHR. A third resident, admitted for rehabilitation and nursing care after a serious fall and hospitalization, had multiple shifts with no documentation of personal care, including hygiene, eating, dressing, and toileting. The DON and NHA were unaware of the lack of documentation and could not provide evidence that care was given during these periods.
Failure to Maintain Accurate and Complete Medical Records for Oxygen Administration
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for a resident who was transferred to the hospital due to shortness of breath. Review of the clinical record showed that the resident experienced a change in condition and was given new orders for oxygen and other treatments by the on-call provider. Documentation from an LPN indicated that PRN oxygen at two liters per minute was administered. However, further review of the resident's medical record did not reveal any physician's order for the oxygen use. The Director of Nursing confirmed that no such order was entered into the resident's medical record.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
Facility staff failed to adhere to professional standards for food safety by not wearing beard restraints during meal preparation and food handling in the kitchen. On two separate occasions, a dietary aide with a long beard was observed making pancakes and preparing resident meal trays without a beard restraint. Additionally, during a subsequent observation, both the corporate Certified Dietary Manager and the kitchen manager, who both had facial hair, were present in the kitchen without beard restraints. These staff members acknowledged not wearing the required protective equipment when questioned. The kitchen manager was informed of the deficiency but did not acknowledge it at the time, while the Nursing Home Administrator later acknowledged the findings during interviews. No information about residents' medical history or condition at the time of the deficiency is provided in the report.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the most recent federal survey results were readily accessible to residents, family members, and legal representatives. During an observation of the entrance hallway, a binder labeled as containing survey results did not include the most recent federal survey findings. The front desk receptionist was unaware of the missing documents until notified by surveyors and subsequently informed the administrator. Both the Regional Nurse Consultant and the Director of Nursing confirmed that the required federal survey tags were not present in the binder. It was also confirmed that the front desk was the only location in the facility where survey results were kept.
Failure to Provide Advance Directive Information to Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a cognitively intact resident with information and opportunities to formulate an advance directive. Upon review of the resident's medical record, there was no evidence of an advance directive or documentation that information or materials regarding advance directives had been offered. The Social Services Assessment and Documentation for the resident indicated that no conversation or materials related to advanced care planning were provided, and all relevant questions were answered in the negative. During interviews, the Social Services Director confirmed that the resident did not have an advance directive in place and that there was no documentation showing that information or opportunities to complete one had been provided. The resident was responsible for making their own medical decisions, and there was no durable power of attorney for healthcare on file. The lack of documentation and provision of information was acknowledged by the Social Services Director during the survey.
Failure to Protect Resident Property Due to Broken Cabinet Lock
Penalty
Summary
A resident reported that personal items, including body wash, shampoo, and $12.00 in cash, were stolen from their room. The resident stated that the lock on their bedside cabinet had been broken for approximately one to two months and that repeated notifications to nursing staff about the issue did not result in any action. During observations, the surveyor noted that the resident's bedside cabinet drawer was open, with a bank envelope containing money and a hearing aid visible and unsecured, and that the resident was unable to lock the drawer. On a subsequent observation, the drawer was again found ajar while the resident was not present in the room. The Director of Nursing acknowledged that the broken lock failed to protect the resident's property and that the resident could not file a grievance without staff assistance.
Failure to Identify Grievance Official and Resolve Resident Grievance
Penalty
Summary
The facility failed to properly identify a Grievance Official in its grievance policy, ensure the policy was followed for processing grievances, and make prompt efforts to resolve a resident's grievance. A resident reported missing hearing aids to staff, who acknowledged the complaint but did not initiate or follow the formal grievance process. The grievance policy reviewed by surveyors was incomplete, lacking the name and contact information of the Grievance Official. Staff interviews revealed confusion about the grievance process, with some staff unaware of their responsibilities or the steps required to resolve grievances. Grievance forms were not readily available at the nurses' station as expected, and there was no clear documentation or follow-up on the resident's complaint. A review of the grievance log showed that the resident had previously filed a grievance regarding the missing hearing aids, which was marked as resolved and signed by the Nursing Home Administrator. However, the resident continued to report the hearing aids as missing, and staff members, including the Social Services Department and unit manager, were unaware of the grievance or its resolution. The Nursing Home Administrator, who identified himself as the Grievance Official, was also unaware of the grievance filed months earlier and acknowledged that the process had failed the resident.
Failure to Document NPIs and Indications Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use, specifically regarding the administration of Ativan (Lorazepam) on an as-needed basis. Record review showed that the medication was administered 16 times in one month, but there was no documentation that non-pharmacological interventions (NPIs) were attempted or provided prior to giving the medication. Additionally, there was a lack of documentation indicating that the resident exhibited behaviors that would justify the use of the psychotropic medication on several occasions. Interviews with the Nurse Manager revealed that nursing staff are expected to document both the behaviors leading to the administration of psychotropic medications and the NPIs attempted beforehand. Multiple avenues for such documentation were available, including the eMAR, medication orders, progress notes, and behavior monitoring tasks. Despite these expectations and available methods, the required documentation was not present in the resident's medical record for the identified dates.
Failure to Provide Written Transfer Notice and Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
A review of the medical record for a resident with moderate cognitive impairment revealed that, following the resident's transfer to an acute care facility, there was no documentation that the resident's representative was provided with written notification of the facility's bed hold policy or a written transfer notice including the reason for transfer. Interviews with facility staff, including an LPN, the director of nursing, and the receptionist, confirmed uncertainty or lack of documentation regarding the process for ensuring these notifications were sent. The deficiency was identified during a review of records and staff interviews, which showed that the required written notifications were not provided as mandated.
Inaccurate MDS Assessment of Insulin Administration
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected a resident's medication usage. Specifically, a review of one resident's medical record showed that the MDS assessment documented insulin injections being administered on all seven days of the assessment period. However, there was no documentation in the medical record to support that the resident had a diagnosis of diabetes, any current or past orders for insulin, or any evidence that injections were given during the look-back period. The MDS nurse reported using the Medication Administration Record (MAR) to complete Section N Medications but was unable to provide supporting documentation for the recorded insulin administration. Upon review, the nurse acknowledged the error in the MDS assessment.
Failure to Complete Required PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that a required Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for a resident with documented mental health and developmental conditions. Record review showed that the resident's PASARR Level I screening did not indicate a trigger for Level II evaluation or a 30-day short-term admission exemption, and there was no evidence of further screening or exemption coordination prior to admission. Despite the resident being care planned for agitation, schizoaffective disorder, and developmental delay, the necessary Level II evaluation was not conducted as required. During staff interview, the facility's social worker confirmed that both preadmission and post-admission PASARR Level I forms lacked documentation of a Level II review or exemption. The post-admission PASARR specifically noted that a Level II was required for intellectual disability, but no Level II clearance was obtained. The deficiency was acknowledged by facility staff and administration during the survey, with no additional evidence provided to demonstrate compliance.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for two residents, as identified during a recertification survey. For one resident with significant cognitive impairment and limited mobility, the care plan did not specify the individual's preferred independent activities, nor did it address important preferences such as pet visits and going outside for fresh air, despite these being documented as very important in the Minimum Data Set (MDS) assessment. Additionally, the care plan for pressure ulcer prevention referenced the use of a bariatric air mattress and required checks for placement and function every shift, but there was no current physician order for the mattress, and documentation of these checks was missing after a certain date. The air mattress was also found to be set incorrectly, and staff were unclear about the correct settings and responsibilities for monitoring the equipment. For another resident, the activity care plan was not individualized to include the resident's preferences for going outside and participating in religious services, as indicated in the MDS assessment. The care plan only mentioned watching TV as an independent activity, omitting other significant preferences. The activities director confirmed that these preferences were not addressed in the care plan. Additionally, this same resident was admitted with pitting edema in both legs, and ongoing provider notes documented continued edema. However, the care plan did not address the resident's edema, despite staff and the director of nursing acknowledging the presence of this condition since admission. These omissions demonstrate a lack of comprehensive and individualized care planning based on residents' assessed needs and preferences.
Failure to Provide Individualized and Ongoing Activity Programs
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and preferences of its residents, as evidenced by the experiences of two residents. For one resident with significant cognitive impairment and limited physical mobility, the care plan did not specify the independent activities the resident enjoyed, nor did it address important preferences such as pet visits or going outside, despite these being identified as very important in the resident's Minimum Data Set (MDS) assessment. Documentation of activity participation was inconsistent, with many days lacking any record of activities, and family or friend visits were frequently documented as the sole activity. The Activity Director confirmed that he did not individualize the care plan to reflect the resident's specific interests and was unaware of which residents received pet visits. Activity documentation over a three-month period showed significant gaps, with many days unaccounted for and limited evidence of meaningful engagement in activities tailored to the resident's preferences. The care plan had not been updated to reflect the resident's current interests or to ensure that important preferences were being met. Another resident, who had dementia and hearing difficulties, was observed sitting in a wheelchair in their room without any meaningful activity. The resident expressed a lack of engagement and was unaware of available activities. The care plan for this resident included goals for participation in group, one-on-one, or independent activities, and the MDS assessment indicated a strong preference for going outside and participating in religious services. However, activity logs showed minimal participation, with only a few documented activities and no evidence that the resident's stated preferences were being addressed.
Failure to Assist Resident in Accessing Hearing Services
Penalty
Summary
A deficiency occurred when the facility failed to assist a resident with significant hearing impairment in gaining access to necessary hearing services. The resident, who is legally blind and hard of hearing, reported to staff that their hearing aid was not working and required a new battery or repair. Despite staff being aware of the issue, the hearing aid remained nonfunctional and was observed unused in the resident's bedside cabinet. Multiple observations confirmed that the resident was not wearing the hearing aid during daily activities, and documentation in the medical record indicated the resident's high level of hearing impairment and need for hearing aids. Interviews with nursing staff revealed a lack of follow-through and communication regarding the resident's need for hearing aid repair. While some staff acknowledged the problem and indicated they would inform the unit manager, the unit manager reported not being made aware of the issue. Additionally, staff reported not receiving training or education on the use or maintenance of hearing aids. The Director of Nursing acknowledged the facility's failure to assist the resident in accessing hearing services to maintain hearing abilities.
Failure to Accurately Implement Wound Care Orders and Air Mattress Settings for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that wound care orders for a resident with a history of pressure ulcers were accurately entered into the electronic health record and that wound care was provided according to those orders. The resident, who had significant cognitive impairment and limited mobility, had a stage 4 pressure ulcer on the left hip. Medical record review showed inconsistencies in the documentation and implementation of wound care orders, including discrepancies in the frequency of dressing changes and missing documentation for several scheduled dressing changes. Orders from the wound specialist were sometimes entered incorrectly, such as being documented as every other day instead of daily, and there were instances where the site of the wound was not specified in the order. Additionally, the facility failed to maintain proper settings and documentation for the resident's bariatric air mattress, which was part of the care plan to prevent further pressure ulcers. The air mattress was observed to be set at 350 lbs, while the resident's weight ranged from 153 to 171 lbs, and staff were unaware of the correct setting. There was also a lack of a current physician order for the air mattress and no documentation that staff were checking the mattress for placement and function every shift as required by the care plan. The previous order for the mattress had been discontinued and not renewed upon the resident's re-admission. Interviews with nursing staff and the DON revealed confusion and lapses in the process for entering and verifying wound care orders and for ensuring the air mattress was set and checked appropriately. Staff acknowledged that errors had occurred in entering orders into the electronic health record and that documentation for required interventions was missing or incomplete. These failures resulted in the facility not providing pressure ulcer care and prevention measures as ordered and documented in the resident's care plan.
Improper Storage of Toxic Chemical in Nourishment Pantry
Penalty
Summary
During a recertification survey, it was observed that a bottle of toilet bowl cleaner containing bleach was stored underneath the sink in the nourishment room of the [NAME] Hall Pantry, which was secured by keypad entry. This area was one of four nourishment pantries inspected. Both an LPN and the unit manager were present during the observation and acknowledged that the chemical should not have been stored in that location. The presence of the hazardous chemical in the nourishment area constituted a failure by the facility to ensure that toxic chemicals were stored safely and appropriately, as required to keep the area free from accident hazards and to provide adequate supervision to prevent accidents.
Failure to Complete Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received annual performance evaluations as required. During the recertification survey, surveyors requested the 2024 annual performance evaluations for three GNAs. The facility was able to provide the evaluation for one GNA but did not have evaluations available for the other two GNAs. The Administrator confirmed that there was no evidence of completed evaluations for these two staff members. The Director of Nursing was informed of these concerns, and no additional documentation was provided before the survey concluded.
Failure to Accurately Reconcile and Document Controlled Medications
Penalty
Summary
The facility failed to establish and maintain accurate systems for reconciling controlled medications according to acceptable standards of practice. During a review of the narcotic books, it was found that one out of four narcotic reconciliations was inaccurately documented. Specifically, a registered nurse signed for both the on-coming and off-going shifts, with the off-going shift signature being inaccurate. The nurse reported that this was how she was trained during orientation and appeared confused about the importance of accurate narcotic shift count documentation. Further review by the unit manager confirmed the early and inaccurate documentation of the nurse's initials on the narcotic sheet. The facility's policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, but this standard was not followed. The Director of Nursing acknowledged that the facility's narcotic reconciliation practice did not meet acceptable standards.
Deficient Medication Regimen Review and Documentation
Penalty
Summary
The facility failed to ensure timely reporting and documentation of pharmacy recommendations during the monthly medication regimen review (MRR) process for two of five residents reviewed for unnecessary medications. For one resident, the pharmacist's MRR report for March was sent late, resulting in the attending physician signing the report after the subsequent month's review had already been conducted. Additionally, the MRR report for April was missing from the resident's medical record. The Director of Nursing (DON) confirmed that the pharmacist's recommendations were not communicated to the facility in a timely manner, and the facility's MRR policy did not specify a timeframe for the attending physician to respond to urgent needs identified by the pharmacist. For another resident, a review of pharmacy recommendations revealed that there was no documentation in the medical record indicating whether the attending provider had reviewed the pharmacist's recommendations or what actions, if any, were taken in response. The DON acknowledged that the required documentation of provider review and response to pharmacy recommendations was lacking. These deficiencies were identified through records review and staff interviews, highlighting lapses in the facility's medication management and documentation processes.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications. A review of medical orders showed that the resident, who had a diagnosis of hypertension, was prescribed a blood pressure medication to be administered every morning and at bedtime, with explicit instructions to hold the medication if the systolic blood pressure was less than 120. Despite these parameters, the medication was administered on multiple occasions when the resident’s systolic blood pressure was below the specified threshold. A review of the electronic Medication Administration Record (eMAR) for April 2025 revealed that the blood pressure medication was given outside the prescribed parameters on several dates and times. The DON confirmed during an interview that the medication was administered inappropriately on these occasions, as indicated by the eMAR documentation.
Failure to Secure and Properly Store Medications and Controlled Substances
Penalty
Summary
Surveyors identified that the facility failed to maintain medical products within expiration dates and in secure locations, as well as failed to have a system to secure access to controlled medications. Specifically, expired lubrication jelly packets were found in the emergency cart, and the Assistant Director of Nursing confirmed their use for airway procedures and acknowledged their expiration. Additionally, diabetic lancets were left unattended on a medication cart in a resident hallway without a nurse present, which was confirmed by both a nurse and the Director of Nursing as inappropriate. Further observations revealed that all four medication refrigerators in the facility lacked properly affixed or present narcotic lock boxes for controlled substances. In some cases, the narcotic box was unattached and could be removed with the shelf, while in others, the lock box was missing or the lock had been broken for at least a week. The Director of Maintenance was unaware of a repair request for the broken lock, and the facility's policy required a substantially constructed storage unit with two locks for controlled substances in areas without automated dispensing systems.
Failure to Provide Routine Dental Services and Lack of Documentation
Penalty
Summary
A deficiency was identified when a resident, who had been in the facility since late 2019 and was cognitively intact, reported never having seen a dentist during their stay. The resident's care plan, initiated in early 2021, documented broken teeth and likely cavities, but there was no evidence in the medical record that dental services had been provided to address these issues. Interviews with the DON revealed that the facility uses a program called Healthdrive to enroll residents for dental services, and the DON initially stated that the resident had refused these services. However, upon review, there was no documentation to support that the resident had refused dental care. The resident also denied ever declining dental services. Additionally, records showed that the facility was deducting a monthly premium from the resident's personal funds for dental services, yet there was no documentation of services provided or refusals.
Failure to Ensure Consistency Between MOLST Forms and EHR Orders
Penalty
Summary
The facility failed to ensure that orders for life-sustaining treatment in the electronic health record (EHR) matched the orders documented on the Maryland Orders for Life Sustaining Treatment (MOLST) forms, and did not maintain the accuracy of physician orders. For one resident, the MOLST form indicated a No CPR (DNR) status with permission to intubate, while the EHR contained an order for DNR and Do Not Intubate (DNI), which did not match the MOLST. Nursing staff reported referencing the MOLST form on the crash cart for code status during emergencies, but would check the EHR for code status during changes in condition. The discrepancy was acknowledged by staff, and it was noted that the MOLST was updated after the EHR order, but the EHR was not promptly updated to reflect the new MOLST instructions. In another case, a resident's MOLST form indicated No CPR, no intubation, and no transfer to the hospital, while the physician's order in the EHR stated DNR, DNI, but allowed transfer to the hospital for unmanaged symptoms. This mismatch between the MOLST and the physician's orders was confirmed by the Director of Nursing and the Nursing Home Administrator during the survey. No additional evidence was provided to resolve the discrepancies by the end of the survey.
Failure to Adhere to Infection Control and Hand Hygiene Protocols
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices for three residents requiring Enhanced Barrier Precautions (EBP) or other infection control measures. For one resident with an indwelling Foley catheter, a CNA transferred the resident without donning gown or gloves, and an LPN entered the room without performing hand hygiene, then hugged and repositioned the resident without using required PPE. Both staff members acknowledged the lapses in infection control. For another resident with a nephrostomy, an LPN entered the room without hand hygiene, donned gloves but not a gown, and began a dressing change. After being prompted by a surveyor, the LPN washed hands, donned a gown, and completed the procedure, but then disposed of the dirty dressing in the hallway while still wearing contaminated PPE. The LPN admitted to not following EBP or proper hand hygiene protocols. A third resident, who was being treated for MRSA and had diabetes, received an injectable medication from a nurse who failed to perform hand hygiene before donning gloves and after removing them. The nurse admitted to missing these steps despite having received prior education on hand hygiene. The facility's policy required hand hygiene before and after glove use, between resident contacts, and prior to medication preparation, but these protocols were not followed during the observed incidents.
Failure to Document COVID-19 Vaccine Offer and Refusal for Staff
Penalty
Summary
The facility failed to offer the most recent COVID-19 vaccine or document the refusal of the vaccine for staff members, as required. During a survey, review of six randomly selected employee files revealed that five staff members did not have documentation indicating they were offered the current COVID-19 vaccine, nor was there documentation of acceptance or refusal. This lack of documentation was confirmed by both the regional Nurse Consultant and the Director of Nursing. The Director of Nursing also reported that one of the staff members was no longer employed at the facility and no declination could be provided for that individual.
Failure to Maintain Safe Operation of WanderGuard Exit System
Penalty
Summary
The facility failed to maintain the safe operating condition of an exit equipped with the WanderGuard System, which is designed to prevent elopement among residents identified as being at risk. Six residents were identified as elopement risks, and one resident, who was non-ambulatory and required a WanderGuard device on their wheelchair, was observed unattended in the main entrance lobby on multiple occasions. Record review confirmed that this resident was care planned for WanderGuard use and required supervision. Staff interviews revealed a lack of knowledge regarding how to assess the functionality of the WanderGuard system. During a demonstration, the WanderGuard alarm was triggered as the resident's wheelchair approached the main entrance, but the sliding glass doors did not close or lock as intended, allowing the possibility for a resident to exit the building. The DON confirmed that elopement risk residents should be supervised and was unaware that the doors could remain open when the WanderGuard system was activated. The deficiency was further substantiated by direct observation and staff acknowledgment that the system did not function as required to ensure resident safety.
Failure to Timely Notify Providers and Representatives of Significant Changes in Condition
Penalty
Summary
The facility failed to notify the attending physician, resident's representative, and registered dietitian in a timely manner when there were documented changes in residents' conditions. In one case, a resident who received all nutrition via tube feedings was identified as having severe malnutrition and was expected to gain weight. However, the resident experienced a significant weight loss of more than 5% in one week and nearly 8% in less than two weeks. Despite facility policy requiring immediate notification of significant weight changes, there was no documentation that the physician, nurse practitioner, registered dietitian, or responsible party were notified of the weight loss until more than a week after it was first identified. Nursing progress notes also failed to document the significant weight loss promptly, and the weight loss was not reported to the dietitian until ten days after it occurred. Additionally, the facility did not immediately notify the attending provider and representative of another resident's fall and subsequent changes in condition, including increased discomfort and changes in the appearance of a surgical incision. The fall and change in condition were reported two and five days later, respectively, rather than immediately as required. Interviews with the DON confirmed that changes in condition should be reported immediately, but the records showed delays in notification. These deficiencies were identified through record review and staff interviews, and were evident for one out of three complaints reviewed during the recertification survey and for one out of three residents reviewed for tube feeding. The lack of timely notification and documentation regarding significant changes in residents' conditions constituted a failure to follow facility policy and regulatory requirements.
Failure to Provide Required Meal Assistance to Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severely impaired cognition, as documented in the Minimum Data Set (MDS), did not consistently receive the required assistance with meals. The resident's medical record indicated a need for set up or clean up help during meals. However, a review of geriatric nurse aides' (GNAs) activity of daily living (ADL) documentation revealed missing records of meal assistance for multiple shifts over a three-month period. Specifically, there was no documentation of meal assistance for 4 shifts in November, 9 shifts in December, and 8 shifts in January. The director of nursing confirmed the lack of documentation during an interview.
Failure to Document and Implement Effective Pain Management Interventions
Penalty
Summary
A deficiency was identified when a resident with a history of post-right hip surgery for a fracture did not receive effective pain management as required. The resident had provider orders for non-pharmacological interventions (NPIs) to be attempted and documented prior to administering PRN opioid pain medication for pain levels between 4 and 10. Review of the medical record and medication administration records (MAR) revealed that while the resident received pain medication on multiple occasions for reported pain levels within the ordered range, there was no documentation of pain assessments prior to medication administration, including the specific location and type of pain, nor any record of which NPIs were attempted before giving the medication. Additionally, after administration of pain medication, the resident continued to experience pain at lower levels on several dates, but the records did not indicate what actions, if any, staff took to further manage the resident's ongoing pain. During an interview, the DON confirmed that her expectation was for staff to attempt NPIs before administering pain medication and to continue managing the resident's pain if it persisted, but the documentation did not reflect these practices.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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