Complete Care At Springbrook
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 12325 New Hampshire Avenue, Silver Spring, Maryland 20904
- CMS Provider Number
- 215052
- Inspections on file
- 16
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Complete Care At Springbrook during CMS and state inspections, most recent first.
The facility failed to report a serious injury of unknown source to the state oversight agency as required. A resident experienced an unwitnessed event, was later found by a spouse with legs hanging off the bed, and subsequently complained of left leg pain, leading to hospital evaluation. Imaging identified an acute left hip periprosthetic fracture of the proximal femur. Facility documentation stated there was no fall and the cause of the injury was unclear, yet the Administrator did not report the incident, believing the injury occurred when the spouse repositioned the resident's legs and that it was therefore not reportable.
A resident experienced an unwitnessed event reported by the spouse, who found the resident’s legs hanging off the bed and repositioned them. The resident later complained of left leg pain and was sent to the ED, where an acute left hip periprosthetic fracture was diagnosed. The facility subsequently discussed the case in a risk meeting and documented that no fall occurred, but did not conduct a timely or thorough investigation at the time of the event to determine how the injury of unknown source occurred, relying instead on an assumption about the spouse’s actions.
A resident was transferred to an acute care facility, but staff did not complete the required MDS discharge assessment. During a complaint survey, review of the resident’s medical record showed no discharge MDS, and the MDS Coordinator confirmed in interview that the assessment had not been done and could not explain how it was missed, resulting in a failure to ensure an accurate assessment process.
A resident with altered mental status, neurological conditions, muscle weakness, and a history of multiple unwitnessed falls was repeatedly assessed as high risk for falls and had a care plan intervention for a fall mat. Despite this, observations on two separate days found the resident in bed without a fall mat in place. The resident had previously sustained hip fractures following unwitnessed falls and an episode where the resident’s legs were found dangling off the side of the bed. The UM and ADON acknowledged that the fall mat should have been in place per the care plan, and record review showed there was no corresponding physician order for the fall mat until the day of the survey.
Multiple residents did not receive medications as ordered due to improper administration techniques, lack of medication availability, and inaccurate documentation. Staff were observed extracting insulin from pens using syringes instead of pen needles, using unlabeled medication containers, and failing to notify physicians when medications were unavailable. The DON was unaware of these practices, and the pharmacist confirmed that the methods used were not appropriate.
Several residents who required assistance with ADLs and had limited mobility were found without access to a working call light system in their rooms and bathrooms. Despite facility policy requiring accessible call lights and prompt reporting of malfunctions, multiple work orders for broken call lights were left unresolved, and no manual call bells were provided. Staff and maintenance were aware of the ongoing issues, but residents remained unable to reliably summon help when needed.
Three residents experienced unsanitary and uncomfortable living conditions due to the facility's failure to replace a damaged, leaking commode toilet and to maintain cleanliness in resident rooms and bathrooms. Persistent odors, visible contamination, and delayed maintenance were observed, with staff and administration aware of the ongoing issues.
Three residents did not receive their prescribed medications as ordered, including a topical analgesic, a pain-relieving patch, an iron supplement, and an oral diabetes medication. In some cases, the correct medication was not available or was substituted with a different product, and in others, the nurse failed to administer the medication as ordered.
Surveyors identified an 11% medication error rate after observing multiple failures, including missed doses, incorrect medication administration, and improper handling of medications by nursing staff. Errors included not administering prescribed pain relief, antihypertensive, iron supplement, and diabetes medications, as well as substituting the wrong topical medication. Staff interviews confirmed these actions did not follow physician orders.
An opened Humalog insulin pen was found on a medication cart with only a handwritten room number and lacking required labeling such as patient name, physician name, and date opened. An LPN confirmed using the unlabeled pen for insulin administration, contrary to facility policy and pharmacy standards that require full labeling of all insulin pens.
Surveyors found that medications were not administered as ordered for several residents, with some doses given late and others not available at the time of administration. In multiple cases, nurses administered medications more than an hour after the scheduled time, and some medications had to be reordered or were missing entirely. There were also instances where medication administration techniques did not follow physician orders, and documentation showed incomplete dosing for prescribed treatments.
A resident with documented hearing and vision difficulties did not have a care plan or interventions developed to address these needs, despite assessments and therapy notes indicating sensory deficits and an order for cerumen impaction treatment. The DON confirmed the absence of a care plan for these issues.
A resident was served a lunch tray containing rice, despite rice not being listed on the resident's meal ticket and the resident's stated dislike for rice. The kitchen manager and administrator both acknowledged this as a staff error.
The facility failed to report abuse allegations within the required timeframe for three residents. A resident with severe cognitive impairment was allegedly slapped by nursing assistants, another with moderate impairment alleged mishandling by a nursing assistant, and a third resident reported verbal abuse by a night supervisor. In each case, the facility did not notify the state survey agency within the mandated two-hour window.
A facility failed to thoroughly investigate an allegation of neglect involving a resident with paraplegia and end-stage renal disease. The investigation lacked interviews with staff assigned to the resident, and the facility could not verify the neglect claim due to insufficient evidence.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in missed treatments and lack of timely assessments. One resident's pressure ulcer deteriorated without prompt consultation with a physician or wound NP, while another resident did not receive prescribed wound treatments consistently. Interviews revealed a lack of awareness and documentation regarding these deficiencies.
A resident with a history of stroke and moderate cognitive impairment did not consistently have physician-ordered bed rails installed, despite a care plan indicating their necessity for safe bed mobility. The facility's failure to ensure the presence of bed rails, due to multiple bed replacements and inaccurate documentation by staff, resulted in a deficiency in accident prevention measures.
The facility failed to maintain complete medical records for at least five years post-discharge for two residents. One resident, with complex medical conditions, had no MARs or TARs available, while another resident's records were incomplete due to management changes. The facility's system limitations and transition issues led to this deficiency, as confirmed by the Administrator and DON.
Failure to Report Serious Injury of Unknown Source to State Agency
Penalty
Summary
The facility failed to report to the Office of Health Care Quality (OHCQ) an incident involving a resident who sustained a serious injury of unknown source where abuse or neglect had not been ruled out. Record review showed that the resident experienced an unwitnessed event in the facility, during which the resident's spouse found the resident with legs hanging off the side of the bed and repositioned them. Staff did not witness the event, and the resident was unable to explain what had occurred. The resident subsequently complained of left leg pain and was sent to the hospital for further evaluation. Emergency Department provider notes documented diagnostic imaging that revealed an acute left hip periprosthetic fracture, described as a new fracture of the left proximal femur. The resident later returned to the facility. Facility documentation indicated that staff concluded the resident did not have a fall in the facility, and the cause of the injury remained unclear. During an interview, the Administrator confirmed that the incident was not reported to OHCQ, explaining that the facility believed the injury occurred when the spouse moved the resident's legs and therefore did not consider the event reportable, despite the serious injury of unknown source.
Failure to Investigate Serious Injury of Unknown Source
Penalty
Summary
Surveyors found that the facility failed to complete a thorough and timely investigation of an incident involving a resident who sustained a serious injury of unknown source. Record review showed that the resident experienced an unwitnessed event in the facility, during which the resident’s spouse reported finding the resident’s legs hanging off the side of the bed and then repositioned them. Staff did not witness the event, and the resident was unable to explain what had occurred. The resident complained of left leg pain and was sent to the hospital, where Emergency Department records documented an acute left hip periprosthetic fracture. Interview and document review revealed that the incident was later discussed in a facility risk meeting, and the facility documented that the resident did not have a fall in the facility. The risk meeting discussion occurred several days after the event, and there was no evidence that a timely or thorough investigation was conducted at the time of the incident to determine how the injury occurred. The Administrator stated that the facility believed the injury happened when the spouse moved the resident’s legs and confirmed that no additional investigation was conducted to determine the cause of the injury.
Failure to Complete Required MDS Discharge Assessment
Penalty
Summary
Facility staff failed to complete a required Minimum Data Set (MDS) discharge assessment for a resident who was transferred to an acute care facility. During a complaint survey, medical record review for Resident #2 showed that the resident was transferred on 2/3/26, but the resident’s MDS record did not contain a corresponding discharge assessment. In an interview, the MDS Coordinator acknowledged that a discharge assessment had not been completed and stated, "I did not do one. I have no clue how this fell off the radar." The Nursing Home Administrator was later informed of this concern by surveyors. This deficiency reflects the facility’s failure to ensure that an accurate and complete MDS discharge assessment was performed as part of the federally mandated Resident Assessment Instrument process, which is intended to identify each resident’s individual needs and support appropriate care planning.
Failure to Implement Care-Planned Fall Mat for High-Risk Resident
Penalty
Summary
The facility failed to implement care-planned fall prevention interventions for a resident identified as high risk for falls. The resident was admitted with diagnoses including altered mental status, hydrocephalus, seizures, intracranial injury, and muscle weakness, and had a documented history of multiple unwitnessed falls on 01/09/2026, 01/15/2026, 02/12/2026, and 02/19/2026. A fall care plan initiated on 02/19/2026 included the use of a fall mat as an intervention. The resident had been transferred to the hospital following an unwitnessed fall that resulted in a confirmed hip fracture and later returned to the facility. Fall risk evaluations completed on multiple dates consistently identified the resident as high risk for falls. On 03/23/2026, the resident’s spouse reported that the resident’s legs were dangling off the side of the bed, after which the resident complained of leg pain and was transferred to the hospital, where a new left hip fracture was confirmed. Subsequent observations on 04/01/2026 and 04/02/2026 showed the resident in bed without a fall mat in place on the right side of the bed, despite the care plan calling for this intervention. During interviews, the Unit Manager and the ADON confirmed that the resident was a high fall risk and should have had a fall mat in place per the care plan, and the ADON stated that there should have been a corresponding physician order for the fall mat. Review of physician orders on 04/02/2026 revealed no active or prior order for a fall mat, and the ADON confirmed that an order for the fall mat was only written that same day.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to provide medication administration that meets professional standards for five of eight sampled residents. For one resident with diabetes, staff were observed extracting insulin from an insulin lispro kwikpen using an insulin syringe, rather than the manufacturer-recommended pen needles. Multiple nursing staff confirmed this practice, citing a lack of compatible safety needles in the facility. The insulin pens used were also not properly labeled with the resident's name, dose, or route, only displaying handwritten dates and room numbers. Staff interviews revealed that this practice had been ongoing for several months, and the central supply manager had instructed staff to use insulin syringes due to supply shortages. The facility pharmacist confirmed that extracting insulin from pens with syringes is not appropriate and can damage the pen, potentially leading to dosing errors. Another resident with a prescription for a topical analgesic did not receive the medication as ordered, despite documentation indicating it had been administered. The nurse responsible stated she thought she had given the medication but had not. For a resident prescribed amlodipine for hypertension, the nurse withheld the medication due to low blood pressure, placed the tablet in an unlabelled medicine cup, and stored it in the medication cart with only a room number written on it. The nurse later administered the medication without a new physician order and could not recall if the resident's blood pressure had increased. The medication administration record did not reflect that the medication was given as ordered. Two additional residents did not receive their prescribed medications (vitron-C and Jardiance) because the medications were not available in the facility. The nurse did not notify the physician about the missed doses. The Director of Nursing confirmed that the affected residents should have received their medications as ordered and that documentation should be accurate. The DON was not aware that staff were using insulin syringes to extract insulin from pens.
Failure to Maintain Functional Call Light System in Resident Rooms
Penalty
Summary
The facility failed to provide a functioning call light system in resident bathrooms and bathing areas, as required by policy, for three residents. The policy mandates that each resident must have access to a call light at the bedside, toilet, and bathing area, with calls relayed directly to staff or a centralized location to ensure timely response. Staff are instructed to report any call light issues immediately and provide alternative solutions until repairs are made. However, multiple work orders for broken call lights remained unaddressed, and no manual call bells were provided in affected rooms. One resident, admitted with diagnoses including infectious gastroenteritis, congestive heart failure, and diarrhea, required assistance with activities of daily living (ADLs) due to limited mobility. This resident's call light was found detached from the wall, with no manual call bell available, making it difficult to summon staff when help was needed. Another resident, who was cognitively intact and dependent on staff for ADLs, reported that the call light in their shared room had not worked for four months, and no manual call bell was present. This resident also expressed concerns about staff responsiveness due to the ongoing issue. A third resident, also dependent on staff for ADLs and identified as a fall risk, was found in a room where both call lights were nonfunctional. Staff were unaware of the broken call lights until the time of observation and interview. The maintenance director acknowledged awareness of the issue and difficulties in obtaining replacement parts, while the administrator and DON were informed of the ongoing problems. Despite the facility's policy and the residents' needs, the lack of a working call system persisted, leaving residents without a reliable means to request assistance.
Failure to Maintain Sanitary and Functional Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for three residents. One resident, who was dependent on staff for all activities of daily living and had diagnoses including spastic quadriplegic cerebral palsy and spinal stenosis, was observed in a room with several dark spots, dried food droppings, and black and brown substances on the walls. The resident reported that the facility did not adequately clean the room or walls. Two other residents, one with unspecified dementia and chronic kidney disease requiring substantial to maximum assistance with personal hygiene, and another with end stage renal disease and a history of falls who was independent with ADLs, experienced ongoing issues with a damaged and leaking commode toilet in their shared bathroom. Both residents reported strong, persistent odors and visible contamination in the bathroom, including black and brown substances on the stool area, stained and discolored floor tiles, and a pervasive smell of urine and human waste. One resident stated the issue had persisted for over two months, leading them to use staff bathrooms instead. Interviews with the Housekeeping Director and Maintenance Director confirmed that the bathroom required significant repairs, including floor and toilet replacement, and that the odor could not be eliminated despite repeated cleaning. Both directors indicated that the administrator was aware of the ongoing plumbing and maintenance issues, which had been present for several months. A private plumber's work order documented repairs to the toilet bowl and recommended further replacement of toilet bolts and pipes.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer medications as ordered by physicians for three residents. One resident with a history of seizures, hypertension, diabetes, and dysarthria did not receive a prescribed topical analgesic (Biofreeze) to the right shoulder as ordered. During observation, the assigned nurse did not administer the medication and later stated she thought she had done so. Another resident with polyneuropathy, diabetes, osteoarthritis, knee pain, vitamin D deficiency, and anemia did not receive a prescribed Salonpas pain relieving patch (lidocaine) to the knees or a Vitron-C tablet for anemia. The nurse on duty administered a different medication (lidocaine and prilocaine cream) instead of the prescribed patch and did not administer the Vitron-C tablet, citing unavailability of the medication. A third resident with diabetes, osteomyelitis, and peripheral vascular disease did not receive a prescribed Jardiance oral tablet for diabetes, as the medication was not available at the time of administration. Both the pharmacist and the Director of Nursing confirmed that these residents should have received their medications as ordered. The deficiencies were identified through record review, medication administration observations, and staff interviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Multiple Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11% with 5 errors out of 43 opportunities. Specific incidents included a nurse failing to administer a prescribed topical analgesic to a resident as ordered, and another nurse not administering an antihypertensive medication due to low blood pressure, subsequently storing the medication in an unlabelled cup in the medication cart and later administering it without confirming the resident's blood pressure status. Additionally, a nurse administered the wrong topical medication to a resident, substituting a lidocaine and prilocaine cream for a prescribed lidocaine patch. Two further errors involved the non-administration of prescribed medications (an iron supplement and a diabetes medication) due to unavailability, with staff confirming that the residents did not receive these medications as ordered. Interviews with staff and the pharmacist confirmed that all residents should receive medications as per physician orders, and the Director of Nursing also acknowledged this expectation. The observed failures included both omissions and incorrect administration of medications, as well as improper medication handling and storage practices, directly contributing to the elevated medication error rate identified during the survey.
Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors observed that an opened and used Humalog (insulin lispro) pen was stored on the West Wing Medication Cart without a label indicating the patient name, physician name, or date used. The only identifying mark on the insulin pen was a room number handwritten with a black marker. Staff Nurse #6 confirmed that he administered insulin using this unlabeled pen and believed that the room number was sufficient for identification. The facility's policy, as provided by the Director of Nursing, requires that insulin pens be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. Further interviews with the Director of Nursing and the pharmacy consultant confirmed that all insulin pens must be labeled with the patient's name, physician name, and date opened. The pharmacy consultant also stated that any opened, unlabeled insulin pens should not be used and that the facility should notify the pharmacy to order a new, properly labeled pen. The failure to label the insulin pen as required by both facility policy and professional standards led to the identified deficiency.
Failure to Administer Medications as Ordered and Ensure Medication Availability
Penalty
Summary
Surveyors identified that the facility failed to ensure medications were administered as ordered for multiple residents. In several observed instances, medications scheduled for administration at specific times were given more than an hour late, and some medications were not available at the time of administration. For example, one resident did not receive lactulose as it was unavailable, and other medications were administered over an hour past the scheduled time. Another resident was missing multiple medications, including an inhaler and furosemide, which had to be reordered, and received the remaining medications late. Additional review of medication administration records revealed that some medications, such as Flonase nasal suspension, were also not available as ordered. The acting DON confirmed that the facility had some ability to pull missing medications from emergency supply but acknowledged the issue of unavailability. Further deficiencies were observed in medication administration technique and documentation. One resident with a gastric tube did not have the tube flushed with water after medication administration as ordered, which was confirmed by the nurse involved. Another resident did not receive all prescribed doses of a medication for cerumen impaction, as the medication was only administered for three days instead of the four days ordered. These findings were corroborated by interviews with nursing staff and review of medication administration records, which showed missed or incomplete doses and deviations from the facility's medication administration policy.
Failure to Develop Care Plan for Sensory Deficits
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing the hearing and vision deficits of a resident. Physical Therapy notes indicated that the resident was educated and engaged in a home exercise program to improve lower extremity strength, and the therapist communicated with the unit manager about the resident's inability to see and hear. The Minimum Data Set (MDS) assessments showed changes in the resident's hearing ability, and the Medication Administration Record (MAR) documented an order for Debrox otic solution for cerumen impaction in the left ear. Despite these documented needs and changes, a review of the resident's care plan revealed that no interventions or care plans were developed for the identified hearing or vision difficulties. The acting Director of Nursing confirmed during an interview that no care plan or interventions were in place for these needs.
Failure to Honor Resident Food Preferences
Penalty
Summary
Facility staff failed to honor a resident's food preferences during meal service. During lunch observation, a resident refused his lunch tray because it contained rice, which he dislikes. Review of the resident's meal ticket confirmed that rice was not listed as part of his meal preferences. The kitchen manager acknowledged that this was an error, and the administrator agreed that the kitchen staff made a mistake in this instance.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required timeframe for three residents. Resident #27, who had severe cognitive impairment, was allegedly slapped by two nursing assistants. The facility was informed of this incident on the morning of December 22, 2022, but did not notify the state survey agency until later that afternoon, missing the required two-hour reporting window. The Administrator was unaware of the late reporting and could not determine why it occurred. Resident #32, with moderate cognitive impairment, alleged that a nursing assistant dropped their legs while providing care. The facility was informed of this allegation on March 24, 2022, but did not report it to the state survey agency until later that evening, again missing the two-hour reporting requirement. The Director of Nursing, who was not employed at the time of the incident, confirmed the reporting delay, and the Administrator was unsure why the report was late. Resident #13, who had no cognitive impairment, alleged verbal abuse by a night supervisor and reported the incident to a corporate representative. The facility was informed of the allegation on December 4, 2023, but did not notify the state survey agency until later that day, outside the required timeframe. The Director of Nursing and the Administrator confirmed the late reporting, acknowledging that the incident should have been reported within two hours of awareness.
Failure to Conduct Thorough Investigation into Alleged Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident with a medical history of paraplegia, end-stage renal disease, pressure ulcer, and dependence on renal dialysis. The resident, who had intact cognition, was transferred to the hospital and subsequently passed away. A family member alleged neglect through a certified letter, claiming the facility did not provide safe and proper medical services to the resident over a specified period. The facility's investigation documents lacked interviews with staff who were directly assigned to care for the resident during the alleged period of neglect. The facility's policy required a comprehensive investigation into allegations of abuse or neglect, including interviews with relevant staff. However, the investigation only included witness statements from staff who were not assigned to the resident during the critical period. The Administrator acknowledged the absence of interviews with the appropriate staff and admitted to losing the certified letter that initiated the investigation. Consequently, the facility was unable to verify the neglect allegation due to insufficient evidence from the investigation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing of pressure ulcers for two residents. For one resident, the facility did not consistently complete and document weekly wound assessments as per the care plan. Additionally, there was a failure to promptly consult with the attending physician or wound nurse practitioner (NP) regarding the deterioration of a pressure ulcer. The resident had a medical history including type 2 diabetes mellitus and peripheral vascular disease, and was admitted with two Stage III pressure ulcers. Despite initial improvements, a new Stage II pressure injury developed and later deteriorated to an unstageable condition without timely intervention or documentation of assessments. For the second resident, the facility did not provide wound treatments as ordered. The resident had a medical history of multiple sclerosis, type 2 diabetes mellitus, and a Stage IV pressure ulcer of the sacral region. The facility's records indicated that the resident's sacral wound treatments were not administered as prescribed, with several treatments missed over a period of time. This resident's wound was debrided weekly by a wound physician, but the facility failed to consistently follow the prescribed treatment regimen, leading to missed treatments and delayed initiation of new treatment orders. Interviews with facility staff revealed a lack of awareness and documentation regarding the missed treatments and changes in wound conditions. The Director of Nursing (DON) and other staff members confirmed that there was no documentation of the wound nurse practitioner being notified of changes in the wound conditions, and there was a lack of consistent wound assessments and timely implementation of treatment recommendations. The facility's policies on pressure injury prevention and management, as well as notification of changes, were not adhered to, contributing to the deficiencies observed.
Failure to Implement Physician-Ordered Bed Rails
Penalty
Summary
The facility failed to consistently implement a physician-ordered intervention for bed rails for a resident, which was intended to assist with safe bed mobility and minimize the risk of falls. The resident, who had a history of cerebral infarction, end-stage renal disease, and moderate cognitive impairment, was admitted to the facility with a care plan that included the use of 1/4 side rails for turning and repositioning. Despite the physician's order and consent from the resident's responsible party, the bed rails were not consistently installed on the resident's bed. Observations and interviews revealed that the resident's bed was replaced multiple times due to mechanical issues, and the new beds did not always come with the required side rails. Nursing staff documented that the side rails were in place, even when they were not, indicating a lack of verification and adherence to the physician's order. The resident reported that the facility was supposed to install bed rails but had not done so, and staff interviews confirmed that the bed rails were not present at times due to bed replacements. The facility's policies on fall prevention and bed rail use were not followed, as evidenced by the lack of consistent implementation of the bed rail intervention. The nursing staff and maintenance personnel failed to ensure that the bed rails were installed on the resident's bed, despite the documented need and physician's order. This oversight led to a deficiency in providing adequate supervision and accident prevention measures for the resident.
Failure to Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete medical records for a minimum of five years from the date of discharge for two residents, as required by their policy. Resident #33, who was admitted with complex medical conditions including acute hematogenous osteomyelitis and end-stage renal disease, had no Medication Administration Records (MARs) or Treatment Administration Records (TARs) available for review. The facility's Administrator acknowledged the inability to retrieve these records from the electronic medical record system for records older than three years, which was contrary to the facility's policy. Similarly, Resident #34, who had a medical history of chronic obstructive pulmonary disease, dementia, and other conditions, was discharged from the facility without complete MARs and TARs for several months prior to discharge. The facility was unable to provide these records, and the Administrator indicated that the records might have been lost during a management transition. Additionally, therapy notes for Resident #34 were not available due to a change in the therapy service provider. Interviews with the facility's Administrator and Director of Nursing confirmed that the expectation was to maintain complete medical records for at least five years post-discharge. However, due to system limitations and management changes, the facility failed to comply with this requirement, resulting in incomplete medical records for the residents in question.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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