Copper Ridge Nursing And Assisted Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sykesville, Maryland.
- Location
- 710 Obrecht Road, Sykesville, Maryland 21784
- CMS Provider Number
- 215265
- Inspections on file
- 19
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Copper Ridge Nursing And Assisted Living Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering and exit-seeking behaviors was able to leave the facility unsupervised after staff failed to recognize and intervene appropriately. Despite documented behaviors indicating risk, no interventions were put in place, and the resident was mistaken for a visitor by staff, allowing them to exit the building. The resident was later found by police and returned after a hospital evaluation.
A review of employee files revealed that several direct care staff, including GNAs and an RN, did not have documentation of required Effective Communication training. The HR Director and Corporate Nurse were unable to produce records confirming the training was completed, citing a lack of systematic record maintenance.
A review of employee files and staff interviews revealed that several staff members, including GNAs and a Dietary Aide, did not have documentation of receiving required QAPI program training. The HR Director and Corporate Nurse were unable to produce or verify records of this mandatory education due to unsystematic record-keeping.
The facility did not report allegations of abuse, injuries of unknown source, and misappropriation of resident property within the required 2-hour timeframe after staff became aware of the incidents. Two residents with unexplained bruising and one resident with a narcotic medication discrepancy experienced delays in reporting to the State Agency, as confirmed by facility documentation and staff interviews.
The facility did not complete required annual performance evaluations for its Geriatric Nursing Assistants, as confirmed by staff and a review of personnel files.
A review of staff files revealed that not all employees received required infection control training, with one staff member lacking documentation of completion. The HR Director and Corporate Nurse were unable to produce or verify records of this training due to unsystematic maintenance of education records.
The facility did not consistently conduct or document interdisciplinary care plan meetings in accordance with required timelines following MDS assessments. For several residents, care plan meetings were either missing or not properly documented to match assessment dates, and staff interviews revealed confusion about the required timing for these reviews.
A resident with high cognitive function was subjected to verbal abuse by an LPN, who spoke aggressively and loudly, causing the resident to become visibly upset and cry. Multiple staff witnessed the incident, and the facility's investigation confirmed the occurrence of verbal abuse.
Surveyors found that two residents were administered psychotropic medications without proper documentation, evaluation, or justification. One resident received PRN Lorazepam almost daily over several months without a 14-day limitation or ongoing assessment, while another was prescribed Rexulti for behavioral symptoms that were not documented in their records. Staff interviews confirmed the lack of observed or recorded behaviors to support the medication orders.
A resident was transferred to the hospital for chest pain, but the facility did not provide written notice of the bed hold policy to the resident or their representative at the time of transfer. Documentation reviewed included only a late entry progress note, a blank bed hold notice, and an undated letter, with no evidence that the required written notice was given.
A resident was not provided with a summary of their baseline care plan and medication list within 48 hours of admission, as required. Review of records and staff interviews confirmed that the necessary documentation and resident acknowledgment were missing, resulting in a deficiency.
Surveyors identified that two residents did not receive care according to physician orders. One resident with weight loss did not have weekly weights obtained as ordered, with some weights missing and others not taken on the specified days. Another resident had a magnesium lab ordered following a pharmacist's recommendation, but the lab was never completed and no results were found. These deficiencies were confirmed through record review and staff interviews.
Surveyors identified that two residents receiving controlled medications had discrepancies between the controlled substance count sheets and the MAR. Doses of Lorazepam and Oxycodone were recorded as administered on count sheets but were missing from the MAR, and in some cases, the timing and dosage could not be reconciled. Interviews with an LPN and the DON confirmed that documentation was incomplete and did not meet facility policy.
A deficiency was identified when facility staff failed to document and respond to a consulting pharmacist's recommendations regarding a resident's medication regimen in a timely manner. The DON kept pharmacy recommendations in a binder rather than in the medical record, and the relevant Monthly Medication Review was not available until prompted by the surveyor, indicating a lapse in following established procedures.
Nursing staff did not follow physician orders for two residents regarding medication administration. One resident received a cardiac medication despite blood pressure readings below the ordered threshold or without a blood pressure check, and another received pain medication when their reported pain level was below the ordered range. The DON acknowledged the errors during review.
A resident reported never having been seen by a dentist since admission and expressed ongoing dental issues. Clinical records confirmed the absence of dental consults, and the DON stated she was unaware of the resident's dental concerns, resulting in a lack of routine dental services.
Staff failed to promptly discard expired protein drinks in two unit-based kitchens, with one staff member returning expired Mighty Shakes to the refrigerator after being notified, while another staff member immediately discarded the expired product.
The facility did not consistently monitor or document antibiotic use, as required by its stewardship program. Two residents receiving antibiotics for urinary tract infections were not included in risk meeting records, and key information such as lab results, signs and symptoms, and antibiotic start and end dates was missing from both the stewardship binder and meeting minutes. The DON confirmed these documentation gaps during the survey.
Two residents were found to have incomplete or missing documentation regarding their influenza and pneumococcal vaccination status. One resident had no record of either vaccine upon admission, and another lacked documentation for the pneumococcal vaccine. The DON confirmed that staff should have obtained and recorded this information, but it was not present in the records reviewed.
Surveyors identified that two residents lacked proper documentation of their COVID-19 vaccination status in their medical records, and one direct care staff member did not have vaccination status documented at the time of hire. The DON confirmed these documentation gaps during the review process.
A resident's call bell was repeatedly found out of reach, first on the floor and later wedged under a wardrobe, making it inaccessible for the resident to request assistance. Staff were aware of the issue but could not immediately resolve it, resulting in the call system remaining unavailable for several days.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to provide adequate supervision to prevent a cognitively impaired resident from eloping. The resident, who had diagnoses including mild neurocognitive disorder with behavioral disturbance and cognitive communication deficit, was admitted with two physician certificates indicating incapacity to make medical decisions. Initial assessments did not identify the resident as an elopement risk, but subsequent BIMS assessments showed moderate to severe cognitive impairment. Nursing progress notes documented behaviors such as refusing care, agitation, wandering, exit seeking, and safety concerns, but no interventions were implemented to address these behaviors. On the morning of the incident, the resident was observed to be agitated, attempting to leave, and even tried to break a window. Staff were notified of the resident's behavior, and a GNA was asked to monitor the resident, but was not assigned to provide one-to-one supervision. The resident was able to access the elevator and reach the kitchen area, where dietary staff mistook the resident for a visitor and allowed them to exit the building. Staff interviews confirmed that the resident did not appear to be a resident and was able to leave the facility without proper verification of identity. The facility's investigation determined that staff failed to recognize and appropriately supervise a resident with exit-seeking behaviors, resulting in the resident eloping from the facility. The resident was later found by police at a gas station several miles away and returned to the facility after a hospital evaluation. The deficiency was attributed to the lack of effective supervision and failure to implement measures to address the resident's documented behaviors and risks.
Failure to Provide Mandatory Effective Communication Training to Direct Care Staff
Penalty
Summary
Facility staff failed to ensure that all direct care staff received mandatory training on Effective Communication, as evidenced by a review of six employee files. Specifically, the files for three Geriatric Nursing Assistants and one Registered Nurse did not contain documentation showing completion of the required training. During the survey, the Human Resources Director was unable to provide evidence that the training had been completed for these staff members. Additionally, the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided.
Failure to Provide Mandatory QAPI Training to All Staff
Penalty
Summary
Facility staff failed to ensure that all employees received mandatory training on the elements and goals of the Quality Assurance and Performance Improvement (QAPI) program. During an extended survey, a review of six employee files revealed that four staff members, including two Geriatric Nursing Assistants, a Dietary Aide, and another staff member, did not have documentation indicating they had received the required QAPI training. The Human Resources Director was unable to provide evidence that the training had been conducted, and the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided. These findings were based on direct review of staff files and interviews with facility personnel, which confirmed the lack of documentation and systematic record-keeping for mandatory QAPI training among the staff reviewed.
Failure to Timely Report Alleged Abuse, Injuries of Unknown Source, and Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made. Specifically, for two residents with injuries of unknown origin, staff became aware of the incidents at 6:15 AM and 8:30 AM, but the initial self-reports to the State Agency were not sent until 11:51 AM and 11:31 AM, respectively, exceeding the required 2-hour reporting window. In both cases, the documentation confirmed the delay in reporting after staff became aware of the injuries. Additionally, an incident involving the alleged misappropriation of a resident's narcotic medication was not reported within the required timeframe. Staff identified a discrepancy in the medication records at 4:00 PM, but the initial self-report to the State Agency was not sent until nearly 24 hours later. These failures to report timely were acknowledged by the Nursing Home Administrator and relevant staff during interviews, with no further comments provided.
Failure to Complete Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct yearly performance reviews for its Geriatric Nursing Assistants (GNAs) as required. During a complaint survey, a review of four GNA personnel files revealed that none contained evidence of annual performance evaluations. When the surveyor requested the performance reviews, facility staff, including Human Resources and a Corporate RN, confirmed that they were unable to locate any documentation indicating that these evaluations had been completed within the past 12 months. This deficiency was identified for all four GNA employee files reviewed.
Failure to Ensure Mandatory Infection Control Training for All Staff
Penalty
Summary
Facility staff failed to ensure that all employees received mandatory training for the Infection Control program, as required by the facility's infection prevention and control policies. During a review of six staff files, it was found that one staff member did not have documentation indicating completion of the required infection control training. The Human Resources Director was unable to provide evidence that the training was completed for this staff member, despite multiple attempts to locate the records. Additionally, the Corporate Nurse confirmed that education records were not systematically maintained, making it impossible to determine if or when the training was provided.
Failure to Conduct and Document Timely Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to conduct and document care plan meetings of the interdisciplinary team for residents at the time of quarterly revisions of their care plans, as required. Review of medical records and interviews revealed that for four out of six residents reviewed, there was either no documentation of care plan meetings or the documentation did not align with the timing of the Minimum Data Set (MDS) assessments. Specifically, care plan meetings were not held or not documented within the required timeframes following quarterly or annual MDS assessments, and sign-in sheets or progress notes did not consistently match the assessment dates. Interviews with facility staff, including the DON and MDS coordinator, confirmed that care plan meetings should be scheduled in relation to MDS assessments and involve an interdisciplinary team. However, discrepancies were found between staff statements and actual practice, with staff unable to provide clear answers regarding the required timing for care plan reviews after MDS assessments. The deficiency was validated by the DON when concerns were presented by surveyors.
Verbal Abuse of Resident by LPN
Penalty
Summary
A resident with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 experienced verbal abuse from an LPN. The incident occurred when the LPN spoke aggressively and loudly to the resident after the resident asked a question, resulting in the resident becoming visibly upset and crying. The resident later reported feeling angry and hurt during a psychological supportive care session. Multiple staff members provided written statements confirming that the LPN used an aggressive tone and loud voice when addressing the resident. The facility's investigation, including witness interviews and review of the resident's medical record, substantiated that verbal abuse had occurred. The Nursing Home Administrator concluded that the incident constituted verbal abuse based on the evidence collected.
Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for two residents. For one resident with dementia, depressive disorder, and anxiety disorder, Lorazepam was ordered and administered as needed (PRN) over an extended period, with orders being renewed continuously from March through June. The medication was given almost daily, sometimes twice a day, without a documented 14-day limitation for PRN use as required. After an initial psychiatric evaluation in April noting the medication's effectiveness, there was no further documented evaluation or rationale for the continued use of Lorazepam, despite its frequent administration. For another resident, a psychotropic medication (Rexulti) was ordered for behavior management related to dementia. However, review of the resident's Minimum Data Set (MDS) and treatment administration records over several months showed no documented behavioral symptoms or incidents that would justify the use of such medication. Staff interviews confirmed that behaviors were not observed or documented during this period, and the psychiatric nurse practitioner acknowledged that the order was based on a single observation of agitation and confusion, with no subsequent behavioral incidents recorded. These findings demonstrate that the facility did not ensure psychotropic medications were prescribed and administered in accordance with regulatory requirements, including proper documentation, ongoing evaluation, and justification for continued use. The lack of appropriate monitoring and documentation resulted in residents receiving unnecessary medications or medications without the required oversight.
Failure to Provide Written Bed Hold Policy Notice Upon Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to a resident or their representative when the resident was transferred to the hospital. Review of the medical record showed that the resident was transferred for evaluation of chest pain, but there was no evidence that written notice of the bed hold policy was given at the time of transfer. The surveyor requested documentation, but the only evidence provided was a late entry progress note stating that the resident and family were notified verbally, a blank bed hold notice form, and an undated letter with a handwritten note indicating it was mailed to the resident's daughter. During an interview, the Nursing Home Administrator (NHA) confirmed that the facility's process is to provide the bed hold policy before a resident leaves for transfer and to keep a copy of the notice. However, the NHA was unable to produce any written evidence that the required notice was given to the resident or their representative at the time of transfer. The surveyor confirmed that the documentation provided did not meet the requirement for written notice.
Failure to Provide Baseline Care Plan and Medication Summary Upon Admission
Penalty
Summary
The facility failed to ensure that a resident was provided with a summary of their baseline care plan (BLCP), including a list of medications, within 48 hours of admission. Review of the resident's medical record showed no evidence that the BLCP or a summary of medications was given to the resident or their representative as required. The BLCP document for the resident was found, but the section for the resident or representative's signature and date, which would confirm receipt of the information, was left blank. Interviews with the DON and NHA confirmed that there was no documentation to show the resident received the BLCP and medication summary within the required timeframe. The deficiency was identified during a recertification/complaint survey, and the lack of proper documentation and resident acknowledgment led to the finding.
Failure to Follow Physician Orders for Weights and Lab Tests
Penalty
Summary
The facility failed to follow physician orders for two residents as identified during a recertification and complaint survey. For one resident with documented weight loss, medical records showed that weekly weights were ordered to be obtained every Sunday for two separate four-week periods. However, weights were either missing or not obtained on the specified days as ordered. Specifically, two out of four required weights were not obtained during the first period, and the remaining weights were not taken on the correct day. In the second period, one required weight was missing, and the others were not obtained on the ordered day. These findings were confirmed by the Nursing Home Administrator during a review of the records. For another resident, a medication regimen review conducted by a pharmacist resulted in a recommendation to order a serum magnesium level, which was agreed to and signed by the provider. An order for the magnesium level was subsequently placed, but there was no evidence in the medical record that the lab was completed or that results were obtained. The Director of Nursing confirmed that no lab results were available for the ordered test. These deficiencies were identified through review of medical records and staff interviews.
Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to ensure that drug records for controlled substances were maintained in a manner that allowed for reconciliation between dispensed and administered medications. During a review of medical records and controlled medication count sheets for two residents, multiple discrepancies were identified. For one resident prescribed Lorazepam 0.5 mg as needed for anxiety, the count sheet indicated doses were administered on two occasions, but there was no corresponding documentation in the Medication Administration Record (MAR). For another resident admitted for recovery from a pelvic fracture and prescribed Oxycodone for pain management, the count sheet documented several administrations of both 5 mg and 10 mg doses, but these were not reflected in the MAR, and in one instance, the timing and dosage could not be reconciled between the two records. Interviews with an LPN and the Director of Nursing confirmed that facility policy requires controlled medication administrations to be documented accurately and consistently on both the count sheet and the MAR. The discrepancies found during the survey indicated that this process was not followed, as the records for the administration of controlled substances could not be reconciled, leading to a deficiency in pharmaceutical services for the residents involved.
Failure to Timely Document and Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to document and respond to recommendations made by consulting pharmacists in a timely manner for one resident reviewed for unnecessary medication use. The DON described the process for handling pharmacy recommendations, which involved printing and placing them in a binder in her office rather than in the resident's medical record or electronic chart. During the survey, the DON was unable to locate the relevant Monthly Medication Review (MRR) for the resident in question, and it was later revealed that the MRR had been held by a staff member until the day before the surveyor's inquiry. There was no documentation in the resident's record to show that the pharmacy's recommendation had been reviewed or acted upon prior to the surveyor's intervention. The deficiency was identified through medical record review and staff interviews, which showed that the facility did not follow its own procedures for timely documentation and response to pharmacy recommendations. The lack of documentation and delayed response to the pharmacist's recommendations regarding the resident's medication regimen, specifically concerning eligibility for Gradual Dose Reduction (GDR), was confirmed by the DON. This failure was evident for one out of five residents reviewed during the survey.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
Facility nursing staff failed to administer medications according to physician orders for two residents. For one resident, the physician ordered Metoprolol 50 mg to be given twice daily, with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. On two occasions, the medication was administered despite the resident's blood pressure being below the specified threshold or not being checked at all prior to administration. There were no progress notes documenting the rationale for administering the medication against the ordered parameters. For another resident, the physician ordered Oxycodone 5 mg to be given every six hours as needed for pain, only if the resident rated their pain between 5 and 10 on a 0 to 10 scale, and to hold for sedation, decreased respirations, or altered mental status. The medication was administered on three occasions when the resident reported a pain level of 4, which was outside the ordered parameters. The DON acknowledged these findings during an interview and was uncertain about when staff education on this issue had last occurred.
Failure to Provide Routine Dental Services
Penalty
Summary
Facility staff failed to ensure that a resident received routine dental services. The resident, who was interviewed, reported never having been seen by a dentist since admission and expressed ongoing dental issues and a desire for care. A review of the clinical record confirmed that the resident had not received any dental consults since admission. During an interview, the DON stated there were no dental consults in the record because she was unaware of any dental problems and believed the resident did not have issues. The surveyor clarified that the resident had reported dental concerns and emphasized that routine dental visits should occur regardless of reported problems.
Expired Nutritional Shakes Not Discarded Promptly
Penalty
Summary
Facility staff failed to discard protein drinks that were past their use by date in two out of three unit-based kitchens observed during a recertification/complaint survey. During a tour of the Eastern Shore nursing unit kitchen, two 4-ounce cartons of vanilla reduced sugar Mighty Shake with a use by date of 5/30/25 were found in the refrigerator, and the staff member present stated she would take care of it but appeared to return them to the refrigerator. In the Baltimore nursing unit kitchen, one 4-ounce carton of the same product, also past its use by date, was found and immediately discarded by the staff member present. The Dietary Manager was informed of these findings and confirmed that the expired Mighty Shakes had been discarded after the surveyor's notification. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Inadequate Monitoring and Documentation of Antibiotic Use
Penalty
Summary
The facility failed to adequately monitor and track antibiotic use among residents, as evidenced by record reviews and staff interviews. The antibiotic stewardship program was found to be lacking in consistent and complete documentation. Although the Director of Nursing (DON) stated that antibiotic use was discussed in daily clinical, weekly risk, and monthly QAPI meetings, the stewardship binder and meeting minutes reviewed by the surveyor contained incomplete or missing information. Key details such as resident admission dates, lab results, signs and symptoms, antibiotic start and end dates, and side effects were frequently absent from the records. The DON indicated that some of the documentation was maintained by the pharmacist and that reviews were conducted through the electronic medical record system, but this information was not consistently reflected in the meeting minutes or stewardship binder. Specifically, two residents who were prescribed antibiotics for urinary tract infections were not listed in the facility's risk meeting minutes, and their antibiotic use was not adequately tracked in the available documentation. The DON acknowledged these gaps when questioned by the surveyor. The lack of comprehensive and consistent monitoring and documentation of antibiotic use led to the identified deficiency in the facility's antibiotic stewardship program.
Failure to Screen and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adequately screen and document the vaccination status for influenza (Flu) and pneumococcal vaccines for two out of five residents whose immunization records were reviewed during a recertification and complaint survey. Specifically, one resident admitted in January 2025 had no documented record for either the Flu or Pneumococcal vaccine. The Director of Nursing (DON) confirmed that staff should have offered the Flu vaccine and obtained the pneumococcal vaccination status upon admission, but there was no data available for this resident. Another resident, admitted in May 2025, also lacked documentation of their pneumococcal vaccine status. When questioned, the DON indicated she would look for additional information, but no further documentation was provided. These findings demonstrate a failure by the facility to ensure proper screening and documentation of required vaccinations for eligible residents as per CDC recommendations.
Failure to Document COVID-19 Vaccination Status for Residents and Staff
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination status for both residents and staff, as identified during a recertification and complaint survey. For two residents, one admitted in May 2025 and another in August 2023, there was either no documentation of COVID-19 vaccination status in the medical record or missing information regarding primary vaccination, despite a recorded refusal of a booster dose. The absence of this documentation was confirmed through medical record review and interviews with the DON, who acknowledged the gaps when questioned by the surveyor. Additionally, a review of employee health files revealed that one staff member hired in December 2024 for direct resident care did not have documentation of COVID-19 vaccination status at the time of hire. Although a declination form was later provided, it was signed only after the surveyor's inquiry, indicating the facility did not have this information on file as required. These findings demonstrate lapses in the facility's process for tracking and recording COVID-19 vaccination status for both residents and staff.
Resident Call Bell Inaccessible in Room and Bathroom
Penalty
Summary
The facility failed to ensure that all residents had access to a functioning call system, as observed during the recertification and complaint survey. Specifically, one resident's call bell was found on the floor and out of reach while the resident was in bed during the initial screening. Subsequent observations revealed that the call bell remained inaccessible, having become wedged under the resident's wardrobe. Staff were made aware of the issue but were unable to immediately resolve it, and the call bell remained out of reach for several days. The deficiency was confirmed through direct observation and staff interviews, with the Nursing Home Administrator being notified of the ongoing issue.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
