Complete Care At Severna Park Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Severna Park, Maryland.
- Location
- 310 Genesis Way, Severna Park, Maryland 21146
- CMS Provider Number
- 215143
- Inspections on file
- 18
- Latest survey
- October 24, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Complete Care At Severna Park Llc during CMS and state inspections, most recent first.
Surveyors found that several residents did not have access to their call bells, with devices placed out of reach in drawers, on the floor, or on the opposite side of the bed. Staff acknowledged responsibility for ensuring call bell accessibility but did not follow a consistent process, resulting in residents being unable to summon assistance when needed.
Multiple residents were found to have nonfunctioning call bell systems, including cases where the alert signal could not be turned off or the call bell failed to signal staff. Some residents reported making repeated requests for repairs that were not addressed, and maintenance staff confirmed that no prior work orders had been submitted for certain rooms. The deficiency resulted in residents lacking reliable access to staff assistance.
Two residents experienced abuse by staff, including verbal aggression and physical force. In one case, a GNA used inappropriate language and yelled at a resident during care, as confirmed by a witness. In another case, a GNA forcibly removed tea bags from a resident's hands, causing pain and weakness, with the incident corroborated by both the resident and a witness. Both incidents were substantiated by the facility's investigation.
Surveyors found that the facility did not report suspected abuse and an injury of unknown origin to OHCQ within the required timeframe for two residents. In one case, a resident's hip fracture was reported late, and in another, staff delayed notifying the Administrator and OHCQ after a resident alleged inappropriate contact by a visitor. The facility's staff misunderstood or failed to follow required reporting timelines.
A resident with intact cognition reported that a GNA forcibly took tea bags from their hands, causing significant pain and weakness. While other residents assigned to the same staff member were interviewed and denied abuse, the facility did not perform required body checks on four non-verbal, cognitively impaired residents, resulting in an incomplete abuse investigation.
A resident who required supervision during meals, as indicated by their care plan and SLP recommendations, was incorrectly documented as independent for eating on multiple occasions. Staff interviews confirmed the resident needed supervision, and the discrepancy was attributed to staff misunderstanding documentation requirements.
The facility did not update care plans after significant events, such as a resident's abuse allegation or medication changes, and failed to ensure care plan meetings included all required interdisciplinary team members. Additionally, there was no documentation that residents were consistently invited to participate in their own care plan meetings, with only family members being invited in some cases.
Two residents experienced abuse by staff, including a GNA yelling and refusing to leave a resident's room, and another GNA providing rough incontinent care and holding a feces-soiled washcloth close to a resident's face. Both incidents were witnessed or reported, and staff failed to ensure residents were treated with respect and free from abuse.
Facility staff did not conduct a thorough investigation after a resident alleged being pushed and choked by a nursing staff member. The investigation lacked interviews with other residents to assess for possible widespread abuse, a gap confirmed by the Administrator during the survey.
Facility staff did not document the delivery of daily wound care for two residents with pressure ulcers, as required by physician orders. Review of treatment administration records revealed multiple dates where wound care was not recorded for wounds on the heel and sacrum. The DON confirmed the lack of documentation for these treatments.
Two residents experienced accidents due to inadequate supervision and failure to eliminate hazards, including a fall from a bed that flipped and a fall during a Hoyer lift transfer. In one case, required incident documentation and investigation were not completed as per facility policy.
A resident recovering from multiple fractures only had a physician order for Oxycodone to be administered for severe pain (pain score 7-10), but staff administered the medication 19 times for lower pain scores (0-6) without an appropriate order. This lack of specific orders for different pain levels resulted in medication being given outside the prescribed parameters.
A resident with a documented history of family trauma did not have trauma-informed interventions included in their care plan. Although the trauma was noted at admission, the care plan lacked specific measures to address these needs, as confirmed by the DON and Administrator.
A facility failed to complete competency evaluations for a newly hired GNA, resulting in an incident of verbal abuse toward a resident. The DON confirmed that competency assessments were not performed at hire, and the GNA's file lacked required documentation. The GNA was terminated and reported following the substantiated abuse event.
Two residents were affected by the facility's failure to monitor behaviors for those on antipsychotic medications and to ensure psychotropic medications were prescribed and documented appropriately. One resident with multiple psychiatric diagnoses received antipsychotic drugs without documented behavioral monitoring, while another was prescribed Seroquel for reasons not supported by diagnosis, with the DON confirming the documentation was inappropriate.
Surveyors found that medications, including a liquid dose and a blister pack of antibiotics, were left unattended and unsecured on two separate units. In both cases, residents with severe cognitive deficits and wandering behaviors were present in the area, and staff were not immediately available to supervise or secure the medications.
Two residents were affected by inaccurate medical record documentation, including incorrect dates for neuro checks after a fall and conflicting information about Seroquel administration in psychiatric notes and the MAR. The DON confirmed these documentation errors during the survey.
Failure to Ensure Resident Call Bells Were Accessible
Penalty
Summary
Surveyors identified that the facility failed to ensure residents had access to their call bells, as required for communication with staff. During observations, four residents were found without accessible call bells: one resident's call bell was inside a bedside table drawer, another's was on the opposite side of the bed, a third had the call bell wrapped around a bed rail out of reach, and a fourth resident's call bell was found on the floor under a roommate's bed. These observations were made while residents were either in bed or seated in wheelchairs, and in all cases, the call bells were not within reach for the residents to summon assistance. Interviews with staff, including a registered nurse and a GNA, confirmed that it was their responsibility to ensure call bells were accessible, but there was no consistent process or schedule for checking call bell accessibility. The staff acknowledged the issue when it was pointed out and repositioned the call bells to make them accessible. The deficiency was further confirmed during dual observations with staff, who admitted the oversight and took immediate action to correct the placement of the call bells.
Failure to Maintain Functioning Call Bell System for Residents
Penalty
Summary
The facility failed to ensure that a functioning call bell system was available for residents, as evidenced by observations and interviews during a complaint survey. Out of seven residents reviewed for call bell function, multiple instances were found where the call bell system did not operate as intended. In one case, a resident's call bell triggered the alert signal but the signal could not be turned off using the wall button, requiring maintenance intervention. The resident reported having previously requested repairs for this issue, but no action had been taken prior to the survey. In another instance, a resident's call bell did not function at all and failed to signal staff when pressed. Staff confirmed that maintenance had not received any prior work orders for this issue. Further review and interviews revealed that additional residents had nonfunctioning call bells, with the Maintenance Director identifying and confirming several rooms where the call bell systems were not operational. Documentation showed that these deficiencies had not been previously addressed, and residents had experienced periods without reliable access to staff assistance through the call bell system. The lack of timely response to repair requests and the absence of maintenance work orders contributed to the ongoing deficiency in ensuring resident safety and communication.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two substantiated incidents involving staff members. In the first incident, a geriatric nursing assistant (GNA) engaged in verbally abusive behavior toward a resident, including yelling and using inappropriate language while providing care. This was corroborated by the resident's roommate's family member, who overheard the GNA's remarks and described escalating verbal aggression when the resident asked the GNA to stop. The facility's investigation confirmed the verbal abuse based on statements from those involved. In the second incident, another GNA was observed forcibly taking tea bags from a resident's hands, resulting in a tugging motion that the resident described as forceful enough to potentially pull them from their chair. The resident, who was cognitively intact with a BIMS score of 15, reported increased pain and weakness in their hands and arms following the incident, with a pain score of 9 out of 10 documented later that day. The incident was substantiated based on the resident's and a witness GNA's statements.
Failure to Timely Report Allegations of Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report suspected abuse, neglect, or theft to the Office of Health Care Quality (OHCQ) within the required timeframe for two residents. In the first case, a resident sustained a left hip fracture of unknown origin, and the initial report to OHCQ was submitted nearly 24 hours after the incident, exceeding the required 2-hour reporting window. The final investigation report was also delayed, being submitted beyond the five working days requirement. The Director of Nursing (DON) incorrectly stated that the facility was required to report within 24 hours, indicating a misunderstanding of the regulatory timeframe. In the second case, a resident alleged inappropriate physical contact by a male visitor, reporting the incident to the Psych Social Worker, Unit Manager (UM), and Social Services Director (SSD). Despite the resident expressing that they did not feel abused and did not want the incident reported, staff failed to immediately notify the Administrator as required by facility policy. The Administrator only became aware of the allegation after the resident's representative contacted the facility the following day. The initial report to OHCQ was submitted more than 24 hours after staff first became aware of the allegation, exceeding the required timeframe. Documentation confirming timely reporting to the Administrator and OHCQ was not provided.
Failure to Conduct Comprehensive Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with intact cognition who reported that a Geriatric Nurse Assistant (GNA) forcibly took tea bags from their hands, resulting in increased pain and weakness in the resident's wrists and arms. The incident was witnessed by another GNA, who described a tugging motion between the staff member and the resident. The resident later reported a pain level of 9 out of 10 and ongoing weakness and tingling in the affected areas. Medical records confirmed the resident was cognitively intact at the time of the incident. During the investigation, the facility interviewed other residents assigned to the alleged staff member, with seven residents denying any abusive encounters. However, the facility did not conduct skin assessments or body checks for four cognitively impaired, non-verbal residents who were also under the care of the alleged perpetrator. Both the DON and the Nursing Home Administrator confirmed that body checks for non-verbal or vulnerable residents were expected as part of the abuse investigation process, but these assessments were not performed.
Inaccurate Documentation of Required Supervision During Meals
Penalty
Summary
The facility failed to maintain accurate documentation regarding the level of assistance required for a resident during meals. The resident's care plan and a speech-language pathologist's recommendation both specified that the resident required supervision while eating. However, a review of the Activities of Daily Living (ADL) documentation for May and June showed that the resident was repeatedly marked as 'Independent' for eating on several dates, which contradicted the care plan and professional recommendations. Interviews with the unit manager confirmed that the resident should not have been considered independent, as supervision was necessary during meals. The unit manager was unable to explain why the resident was documented as independent on those occasions. The administrator acknowledged that the discrepancy was likely due to staff not understanding the difference between 'Independent' and 'Supervision' when documenting the resident's level of assistance.
Failure to Revise Care Plans and Hold Proper Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plans were revised and care plan meetings were held as required for several residents. In one case, a resident who reported an allegation of abuse did not have their behavioral care plan updated following the incident, despite the care plan being last revised prior to the event. Another resident continued to have an active care plan for anticoagulant therapy even after the medication was discontinued, with no update to reflect the change in treatment until it was brought to staff attention during the survey. Additionally, care plan meetings did not consistently include all required interdisciplinary team members. Documentation showed that meetings for one resident were attended by social services, nursing, and the dietician, but not always by the full interdisciplinary team as required. In some instances, the family was notified but did not attend, and there was inconsistency in the presence of therapy staff and other disciplines based on the resident's needs. There was also a lack of documentation confirming that residents were invited to attend their care plan meetings. For one resident, records indicated that only the family had been invited to multiple care plan meetings, with the resident attending just one meeting since admission. There was no evidence in the documentation that the resident had been invited or had declined to attend the other meetings, and the facility could not provide documentation to confirm that invitations were extended to the resident as per their stated process.
Failure to Protect Residents from Verbal and Physical Abuse
Penalty
Summary
A staff member failed to treat a resident with respect and free from verbal and physical abuse, as evidenced by a witnessed verbal altercation between a resident and a Geriatric Nursing Assistant (GNA). The GNA was overheard yelling and cursing at the resident, refusing to leave the resident's room until a supervisor intervened and separated them. The resident reported that the GNA was yelling because the resident did not want to see pictures on the phone about previous staff and wanted the GNA to leave. The incident was witnessed and documented in the facility's investigation packet. In a separate incident, another resident reported that a male GNA was rough during incontinent care, causing pain, and held a feces-soiled washcloth close to the resident's face, asking if the resident wanted to stay like that. The resident reported the incident to the Unit Manager, who confirmed being told about rough care but not about the washcloth. The GNA admitted to being told he was hurting the resident but denied causing pain and continued care. The DON was unaware of the incident until informed by surveyors and later confirmed the GNA's behavior as inappropriate.
Failure to Thoroughly Investigate Abuse Allegation
Penalty
Summary
Facility staff failed to thoroughly investigate an allegation of abuse made by a resident, who reported being pushed and choked by a nursing staff member. The facility's investigation into the incident did not include interviews with other residents to determine whether there was evidence of widespread abuse by staff. This omission was confirmed during an interview with the Administrator, who acknowledged that the investigation lacked resident interviews to disprove broader abuse concerns. The deficiency was identified during a complaint/annual survey, and the findings were based on medical record review and staff interviews. The report specifically notes that the investigation was incomplete due to the absence of additional resident interviews related to the abuse allegation.
Failure to Document Daily Wound Care for Pressure Ulcers
Penalty
Summary
Facility staff failed to document the delivery of daily wound care for residents with pressure ulcers, as evidenced by a review of medical records and treatment administration records (TARs) for two residents. One resident, observed with specialized heel protectors, had a physician order for daily wound care to the left heel, but the TAR showed no documentation of treatment on several specified dates. The Director of Nursing (DON) confirmed the absence of documentation for these dates and acknowledged that wound care should be signed or initialed when performed. A second resident, who had physician orders for daily wound care to the right heel and sacrum, also had missing documentation in the TAR for multiple dates across two months. The DON reviewed the records and confirmed that there was no documentation for the required wound care on the specified dates for both the right heel and sacral wounds. No additional documentation was provided by the facility at the time of the survey exit.
Failure to Prevent Accidents and Complete Required Incident Documentation
Penalty
Summary
The facility failed to ensure residents were free from accident hazards and did not provide adequate supervision to prevent accidents, as evidenced by two separate incidents involving two residents. In the first case, a resident was found on the floor in their room after their bed had flipped onto its side, though not onto the resident. Despite facility policy requiring completion of an incident report and documentation of all assessments and actions following a fall, no incident report or investigation was completed for this event. The Director of Nursing confirmed that the required documentation was not done, and no additional documentation was provided to the surveyor. In the second case, another resident reported falling to the floor when a Hoyer lift tilted during a transfer from wheelchair to bed. The resident subsequently experienced back pain and was transferred to the emergency department. The incident was documented in the medical record, and interviews revealed that the transfer was being performed in the hallway due to limited space in the resident's room. The Hoyer lift involved was removed from service and inspected, but no mechanical issues were found. The facility had been in the process of replacing older Hoyer lifts, and the one involved in the incident was replaced following the event.
Failure to Obtain Orders for Pain Management at Lower Pain Levels
Penalty
Summary
A deficiency was identified when a resident admitted after a fall with multiple fractures, requiring healing and physical therapy, did not have a physician order to address and medicate pain levels below a score of 7. The medical record review showed that the only pain medication order was for Oxycodone 5 mg, 2 tablets every 4 hours as needed for severe pain, defined as a pain score of 7-10. Despite this, the medication administration record indicated that Oxycodone was administered 64 times, including 19 instances for pain scores between 0-6, for which there was no corresponding physician order. This issue was confirmed through review of the resident's records and discussion with the facility's Director of Nursing.
Failure to Provide Trauma-Informed Care Planning
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who disclosed a history of family trauma that led to running away from home at a young age. Upon review of the resident's medical record, it was found that although the trauma was documented at admission, there was no evidence that the care plan included interventions addressing the resident's past trauma. The DON confirmed that trauma-informed assessments are required at admission and after changes in condition, but acknowledged that no care plan interventions were created for this resident's trauma history. Both the DON and the Administrator verified the absence of trauma-related interventions in the resident's care plan.
Failure to Assess GNA Competency at Hire Leads to Abuse Incident
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) were competent in their skill sets, as evidenced by the lack of completed competency skills evaluations or check-off sheets for a newly hired GNA involved in a substantiated incident of verbal abuse toward a resident. Upon review of the employee file, it was found that no competency assessment had been conducted at the time of hire, and the Director of Nursing confirmed that staff competencies were only assessed if an incident occurred, rather than as part of the initial orientation process. Although 60-day and 90-day evaluations were present in other new employee files, the GNA in question did not reach the 30-day mark before being terminated and reported for the abuse incident.
Failure to Monitor Antipsychotic Use and Ensure Appropriate Psychotropic Medication Documentation
Penalty
Summary
The facility failed to adequately monitor the behaviors of a resident receiving antipsychotic medications and did not ensure that residents were free from unnecessary medications. One resident with diagnoses including Bipolar Disorder, Psychosis, Major Depressive Disorder, and Schizoaffective Disorder was prescribed Fluphenazine and Olanzapine. Although a care plan was initiated for hallucinations, anxiousness, and agitation, there was no evidence in the medical record that the resident's behaviors were being monitored as required. Staff interviews confirmed the lack of documented behavioral monitoring for this resident. Additionally, another resident was prescribed Seroquel, a psychotropic medication, with the reason for use documented incorrectly in the Medication Administration Record. The medication was listed as being prescribed for sundowning and as a supplement, which was acknowledged by the DON as inappropriate and not supported by the resident's medical diagnosis. These findings demonstrate failures in both monitoring and documentation related to the use of psychotropic medications.
Unsecured Medications Observed on Units with Cognitively Impaired Residents
Penalty
Summary
Surveyors observed that the facility failed to properly secure medications on two separate nursing units. On one occasion, a medicine cup containing a clear liquid was left unattended on top of a medication cart in a secure dementia unit. Two residents with documented severe cognitive deficits and wandering behaviors were present in the immediate area, and no staff were observed nearby at the time. The medication cart was later identified as belonging to an RN, who confirmed the medication was for another resident. In a separate incident, a blister pack containing 28 tablets of an antibiotic was found unattended at a nursing station desk. The medication was intended for a resident and had been separated for different halls, but was not secured in the appropriate medication cart. The medication remained unattended until a staff RN was questioned and subsequently secured the medication. Both incidents involved residents with significant cognitive impairments and occurred in areas where staff were not present to supervise the medications.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as evidenced by errors in documentation related to neurological checks and psychiatric medication records. For one resident who experienced a fall, neurological checks were documented with incorrect dates, with entries reflecting dates that did not correspond to the actual event. Despite a correction to one entry, subsequent documentation continued to show inconsistent and inaccurate dates. The DON confirmed the expectation for accurate documentation and acknowledged the issue when it was brought to her attention. For another resident, psychiatric notes inaccurately stated that Seroquel had been discontinued months prior, and therefore a gradual dose reduction (GDR) was not attempted. However, a review of the Medication Administration Record (MAR) did not show an order for Seroquel at the time indicated in the psychiatric notes, and the first order for Seroquel appeared months later. The DON and surveyor confirmed the discrepancies between the psychiatric notes and the MAR, indicating inaccurate documentation regarding the resident's medication history.
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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