Crescent Cities Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Riverdale, Maryland.
- Location
- 4409 East West Highway, Riverdale, Maryland 20737
- CMS Provider Number
- 215323
- Inspections on file
- 19
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Crescent Cities Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Meals were not served according to predetermined menus. A resident reported receiving items that did not match the meal ticket, and a tray-line observation found multiple trays missing ordered beverages or receiving incorrect texture-modified items, including a pureed diet item served whole and a chopped dessert served whole. Staff also confirmed that milk, juice, and thickened liquids were supposed to be available, but the unit refrigerators were empty.
Ice machines were not maintained in a clean and sanitary manner. During survey, one machine had a cleaning schedule showing it was last cleaned months earlier, and another machine in a nourishment room had no cleaning log. A later review found a modified log reflecting monthly cleanings, while the RDM stated maintenance kept the logs in its office. The facility’s policy required regular inspection and preventive maintenance of all ice machines.
The facility failed to have an onsite IP responsible for the infection prevention and control program. The DON and NHA stated the IP had resigned, and a sister-facility IP was only assisting remotely by email and virtual attendance at Risk and QAPI meetings. The DON, who was not IP certified, collected the infection prevention data and sent it to the sister-facility IP, while the NHA acknowledged the need for an in-house IP and said resumes were being reviewed.
A resident record review and staff interviews showed the facility did not document that the resident or representative received written information about the right to accept or refuse treatment and the option to complete an AD. The SW stated ADs should be uploaded on admission or discussed during the psychosocial assessment, but the resident's assessment had no AD on file and the education section was left blank. The SW later confirmed there was no documented evidence that the required written AD education was provided.
A resident’s care plan did not address an active infection or antibiotic treatment needs, even though the MAR showed a cefTRIAXone order for a 5-day course to treat a bacterial infection. The care plan instead focused on opioid-related complications without documented opioid orders since admission, and the DON confirmed that infection and antibiotic use should have been included in the care plan.
A resident who spoke Spanish had personal care needs communicated through a housekeeper when the resident pointed to the perineal area. Staff reported that Spanish-speaking residents were often interpreted by housekeeping or maintenance staff, while other staff gave inconsistent answers about the language line and communication tools. The DON confirmed that using ancillary staff to interpret clinical needs was inappropriate, even though a communication board was posted and the care plan referenced a Spanish/English picture chart.
Inaccurate smoking and cognitive assessments were documented for an active smoker. A surveyor observed cigarettes and a lighter in the resident’s drawer, and the resident confirmed the facility allowed smoking materials to be kept in the room. The chart and MDS incorrectly coded the resident as not smoking, while BIMS scores in the record varied and were later said to have been coded in error. The NHA confirmed the resident smoked and validated the findings.
Failure to address and communicate significant weight changes for two residents. One resident had large, fluctuating weight changes with no documentation that the early drops and gains were investigated, re-weighed for accuracy, or addressed with interventions. Another resident had a 14.6 lb weight loss after hospitalization, but there was no evidence the provider was notified. The DON validated the lack of documented communication, and the Dietitian stated significant weight changes should be addressed and that nursing is responsible for reporting them.
The facility failed to provide ordered respiratory care for three residents receiving O2 therapy. Two residents were observed with unlabeled O2 tubing, and their records showed orders for weekly tubing changes and labeling per protocol. Another resident was observed receiving O2 at 2.5 L/min even though the order was for 2 L/min, and staff stated they sometimes increased the flow without an order; the resident also had no care plan for oxygen administration.
Incomplete GNA Competency Validation: The facility failed to ensure that newly hired GNAs had documented competency in required skills before providing resident care. Surveyors reviewed four GNA files and found multiple blank or incomplete skills validation sections, including infection control, equipment use, clinical skills, and specialized care needs. The DON confirmed the competencies were not fully documented and that no additional records showed the GNAs were verified before starting work.
A resident was observed screaming, yelling, and crying, and staff attributed the behavior to pain before later involving psych services. Record review showed an earlier psych consult found the resident stable, but a later NP note addressed visual hallucinations and verbal outbursts without prior documentation of those behaviors or any attempted interventions in the chart. The DON validated the findings.
Delayed Response to Pharmacist Medication Review Recommendations: The facility did not timely address consulting pharmacist recommendations for multiple residents. One resident continued receiving sliding scale insulin and had delayed follow-up on clopidogrel monitoring, another continued receiving PRN tizanidine despite a recommendation to discontinue or limit it, and a third received risperidone without a documented allowable diagnosis for an extended period. The DON acknowledged that the pharmacist’s concerns were not properly resolved.
An LPN made two medication administration errors during a medication pass for a resident with a PEG tube, resulting in a 7.69% error rate. The LPN gave acetaminophen 500 mg via gastric tube instead of the ordered 325 mg, 2 tablets orally, and administered a multivitamin tablet via gastric tube instead of the ordered liquid multivitamin via PEG-tube.
A prescribed skin cream for a resident was observed unattended on the window ledge during the initial tour, despite being labeled for that resident and having instructions to refrigerate it. An LPN said staff had recently provided personal care to the resident, and the DON later acknowledged the surveyor’s findings. The resident’s TAR showed an order for Greers [NAME] Cream to be applied topically twice daily for erythema interigo.
Food was not consistently served at appropriate temperatures. A resident reported that hot foods were usually served cold, and during a tray line observation, staff delayed tray distribution after the meal cart reached the unit. The Dietary Manager tested the tray and found hot items at 140 F and 134 F, while coleslaw was 86 F, below the facility’s standards for hot and cold foods.
A resident with DM and ESRD reported receiving foods that did not match the resident’s medical needs, including items the resident said should have been restricted. The chart showed only a heart-healthy diabetic diet order, while nursing notes documented concerns from the resident and family about foods that could not be eaten due to ESRD, but no diet order change was found. The CDM said restricted foods were kept in personal notes for the cook, and the RD stated the order should have been a renal diet.
Failure to use PPE during PEG tube medication administration. An LPN administered a resident’s medication through a PEG tube while an EBP sign was posted at the room entrance, but did not use the required gown and gloves during the task. The DON was later informed of the observation and acknowledged the concern.
A resident suffered a right femur fracture after being struck by a Hoyer lift during a transfer, due to the facility's failure to ensure safe transfer practices. Despite the resident expressing fear of the lift, the incident was not reported or documented by staff, and no investigation was conducted. The facility's policies on reporting and using mechanical lifts were not followed, and training on lift use was inadequate.
The facility failed to provide palatable and appropriately tempered meals to residents, as evidenced by consistent complaints about cold and unappetizing food. Observations revealed delays in meal delivery due to inadequate equipment and staffing, with trays left on carts for extended periods. The Dietary Manager noted issues with heating equipment, and the Administrator acknowledged the need for improvements.
A resident with severe cognitive impairment was not treated with dignity during meals. Staff stood over the resident while feeding, did not offer an alternate meal when the resident spat out food, and left a tube of A&D Ointment near the meal tray. The resident eventually received a preferred alternate meal after staff intervention.
A resident admitted for subacute rehabilitation services was improperly discharged to another facility without adequate documentation or agreement. Despite expressing a desire to return home and having decision-making capacity, the resident was transferred without a discharge care plan or proper notification to their representative. The facility's Director of Social Services cited safety concerns and Medicaid application issues, but no documentation supported a resident-initiated discharge or agreement with the transfer.
A facility failed to issue a 30-day transfer notice to a resident before transferring them to another facility. The resident received a Notice of Medicare Non-Coverage indicating benefits would end soon, but was discharged without initiating or agreeing to the transfer. Interviews confirmed the resident wanted to return home, not be transferred.
A facility failed to provide adequate discharge planning for a resident admitted for aftercare of a right femoral fracture, high blood pressure, and cardiomyopathy. Despite plans for the resident to return home and being ordered occupational and physical therapy, the facility did not initiate a discharge care plan. Interviews revealed that the Discharge Planner discussed discharge and insurance benefits but was not responsible for the care plan, and the Director of Social Services confirmed the care plan was not initiated upon admission.
A facility failed to adequately monitor a resident's pain, leading to delayed treatment for a fractured ankle. The resident, who was non-verbal and had memory issues, did not have an alternative pain scale available for accurate pain assessment. The MAR lacked documentation for pain scores, preventing effective pain management.
The facility failed to maintain a medication error rate below five percent, with errors observed during medication administration for two residents. One resident received Plaquenil without proper timing confirmation, and another received sucralfate after eating and insulin at the wrong time. Staff did not adhere to the facility's medication administration policy.
A cognitively impaired resident was not offered an alternate meal despite showing clear signs of disliking the served pureed meal. The Unit Manager did not follow the facility's policy to offer alternatives, although alternate options were available. The resident eventually received a preferred meal after staff intervention.
The facility failed to ensure proper PPE use during wound care for a resident on Enhanced Barrier Precautions, as staff did not wear gowns. Additionally, an LPN improperly handled medication by administering a pill that had been dropped onto the medication cart. Both incidents were confirmed by staff and acknowledged by the Infection Preventionist.
The facility failed to properly review and document admission agreements for two residents, one with severe cognitive impairment and another unable to participate in the assessment. In both cases, the signatures and initials on the admission contracts were inconsistent and could not be verified, and the responsible employees were no longer employed at the facility.
A facility failed to ensure the correct person was identified to make medical treatment decisions on a MOLST form. A resident's initial request for full code status was changed to 'do not resuscitate/do not intubate' based on a surrogate decision maker's choice, despite the resident's initial wishes. The change was documented as discussed with the resident and family, although the resident was certified incapable of making medical decisions. The facility social worker acknowledged the inappropriate change.
The facility failed to report injuries of unknown origin for two residents within the required timeframes. One resident with a dislocated hip was reported to the SSA a day late, and the follow-up report was submitted eight days after the injury was discovered. Another resident's injury was not reported at all, as the facility believed they knew the cause. These actions violated the facility's policy and regulatory requirements for timely reporting.
The facility failed to thoroughly investigate injuries of unknown origin for two residents, as investigations lacked interviews with other residents to assess potential abuse or neglect by staff. One resident had a dislocated right hip with a comminuted fracture, and another sustained a right ankle fracture, but the causes were undetermined. The DON and Administrator confirmed the absence of resident interviews in the investigations.
The facility failed to follow physician orders and document care for two residents. One resident did not receive a dental consult despite a physician's order, and behavior monitoring was inadequately documented. Another resident's stool sample was not collected for analysis as ordered. The DON acknowledged these issues but could not provide explanations or solutions.
A resident with multiple pressure ulcers and deep tissue injuries was not provided with a recommended vascular consult and doppler exam, as identified during a survey. Despite the wound care team's recommendation and the facility staff's awareness, the necessary follow-up was not completed, leading to a deficiency.
A facility failed to maintain accurate medical records when an LPN marked a stool specimen collection task as completed for a resident, despite the task not being performed due to the resident not having a bowel movement. This discrepancy was confirmed by the Regional Clinical Nurse, who noted that a check sign on the TAR indicates task completion.
The facility's failure to update its Facility Assessment annually resulted in outdated staff and resident information, with the last update on February 6, 2023, and resident data from January 2022. This could negatively impact all 151 residents by not accurately assessing their current needs. The Administrator and RDO confirmed the need for current information.
Meals Not Served According to Predetermined Menus
Penalty
Summary
The facility failed to ensure that residents were served meals according to predetermined menus. During a lunch tray line observation, 4 of 6 randomly selected trays did not match the meal tickets, including missing ordered beverages and incorrect texture modifications. Resident #92’s tray lacked the apple juice, milk, and coffee listed on the ticket; Resident #34, who was ordered a pureed diabetic diet with thin liquids, received a cake that was not pureed as ordered and also did not receive the ordered beverages; Resident #121’s tray did not include the ordered honey-thick apple juice, dairy, or coffee; and Resident #48’s tray included a cake brought to the floor whole instead of chopped as ordered. Earlier, Resident #1 reported frequently receiving items that did not match the meal ticket and described a breakfast on 2/22/26 where the resident expected orange juice, hot cereal, and milk but received a pink drink and oatmeal instead. The meal ticket for that meal listed apple juice, milk, and coffee. The CDM confirmed that juice and coffee were provided based on meal tickets and distributed by GNAs and nurses. The surveyor also found that only fruit punch and ginger ale were brought to the unit, while the CDM stated milk, juice, and thickened liquids were stocked in unit refrigerators; however, the UM and surveyor inspected the unit and dining room refrigerators and found them empty.
Ice Machines Not Maintained With Consistent Cleaning Logs
Penalty
Summary
The facility failed to maintain the ice machines in a clean and sanitary manner. During the initial kitchen tour with the CDM, the surveyor observed that one ice machine’s cleaning schedule showed it was last cleaned on 9/25/25, and the document also listed a lower level kitchenette location, a filter date of 2/22/25, and a checked mark next to cleaned with the comment “is Good.” The CDM stated that the maintenance department should clean the machines monthly, and the Regional Dietary Manager acknowledged the observation. A second ice machine in the second floor Terrapin nourishment room had no cleaning log when inspected with LPN #5. On a later follow-up visit to the kitchen, the surveyor observed that the ice machine cleaning log had been modified to reflect monthly cleanings from 1/21/25 through 1/30/26. The Regional Dietary Manager stated that maintenance kept the logs in their office and acknowledged the concern. Staff #8 stated the facility had a total of 5 ice machines, that the machines were checked and cleaned monthly, and that posting logs on the machines began in September 2025. The facility’s Ice Machines policy dated 5/1/22 stated that all ice machines were to be inspected regularly with preventive maintenance performed monthly, quarterly, and semi-annually.
Missing Onsite Infection Preventionist
Penalty
Summary
The facility failed to have an Infection Preventionist onsite to be responsible for the infection prevention and control program. During an interview, the DON and NHA stated that the facility’s Infection Preventionist resigned on 1/26/26. The DON stated that an Infection Preventionist from a sister facility was assisting with oversight of the program, but that person was never in the building and provided infection prevention and control information by email and through virtual attendance at Risk and QAPI meetings. The DON also stated that he was not IP certified, but he collected the required infection prevention and control data and emailed it to the sister facility IP. During a follow-up interview, the NHA stated that he knew the facility should have an in-house Infection Preventionist and that a job posting was active with resumes being reviewed for the position.
Failure to Document Advance Directive Education
Penalty
Summary
The facility failed to provide documented evidence that all residents and/or representatives received written information about the right to accept or refuse medical or surgical treatment and the option to formulate an Advance Directive. This deficiency was identified for Resident #166 during record review and staff interviews. The Social Worker stated that Advance Directives were to be uploaded to the electronic health record on admission, or discussed during the Discharge Planning Psychosocial Assessment if not available, but also acknowledged that the assessment form may not have been accurately checked or completed. Review of Resident #166's Discharge Planning Psychosocial Assessment showed no existing Advance Directive, and the section documenting education about initiating an Advance Directive was left blank. The Social Worker later verified that the resident's Advance Directive was not obtained on admission and confirmed there was no documented evidence that the required written education was provided to the resident or representative(s).
Incomplete and Non-Resident-Specific Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #32. Record review showed an order dated 01/29/2026 for cefTRIAXone Sodium Injection Solution Reconstituted 2 gram once daily for a 5-day course to treat a bacterial infection, but on 02/27/2026 the resident’s care plan did not address the infectious disease process or the antibiotic treatment needs. The care plan instead included a risk for complications related to opioid use, even though there was no documented evidence that the resident had orders for opioids since admission, making the care plan not resident specific. The DON confirmed that if a resident had an infection and was receiving antibiotics, that information should have been addressed on the care plan, and stated that Nurse Managers/Supervisors were responsible for care plan development and accuracy.
Failure to Use Appropriate Communication Methods for a Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure staff used a functional communication system to communicate personal care needs for a non-English speaking resident. During the initial pool phase of the annual survey, the resident called out and pointed to the perineal area, and staff were notified of the need for assistance. Staff entered the room with a housekeeper, and staff later confirmed that communication with Spanish-speaking residents was often done by using Spanish-speaking staff and, at times, housekeeping staff to interpret the resident's needs. Interviews showed inconsistent knowledge of the facility's communication resources. An LPN stated that housekeeping and maintenance personnel were commonly used to interpret the resident's needs and was unsure whether a language line was available. The social worker stated that staff sometimes used Google Translate and that a language line was available. The DON reported that expectations for non-English speaking residents included care planning for communication issues, use of a communication board, Google Translate, and an interpreter phone line, but also confirmed that using ancillary staff such as housekeeping to interpret clinical needs was inappropriate. Observation of the resident's room showed a basic communication board posted on the wall, but staff interviews did not identify it as a communication method. The resident's care plan stated the resident was dependent on staff and family due to the language barrier and that staff should use a Spanish/English picture chart to communicate.
Inaccurate smoking and cognitive assessments for an active smoker
Penalty
Summary
The facility failed to provide an adequate smoking evaluation and safety assessment for one resident who was identified during the survey as an active smoker. During the initial tour, the surveyor observed three packages of cigarettes and a lighter in the resident’s drawer, and the resident stated that the facility allowed residents to keep smoking materials in their possession. A review of the medical record showed that smoking assessments were completed on admission and quarterly, but the most recent quarterly assessment incorrectly documented that the resident did not smoke. The MDS assessment also documented the resident’s smoking status as no. During follow-up interviews, the resident confirmed being an active smoker, and the NHA confirmed the resident smoked. The NHA stated that residents with a BIMS score of 10 or higher were permitted to keep their own smoking materials, while those below 10 were not. Review of the resident’s recorded BIMS scores showed a score of 10 on one assessment, then scores of 7 and 8 on later assessments. The NHA later stated that the Social Worker said the resident’s BIMS had been coded in error and had just been corrected, and a new BIMS assessment with a score of 13 was submitted during the survey. The surveyor expressed concern that the smoking assessment had been incorrectly coded since August 2025 and that the resident’s cognitive status had not been accurately reflected to ensure safety, and the NHA validated these findings.
Failure to Address and Communicate Significant Weight Changes
Penalty
Summary
The facility failed to timely address and communicate significant weight changes for Resident #11 and Resident #143. For Resident #11, the medical record showed marked and fluctuating weights in August and September 2025, including a drop from 143 lbs to 115.1 lbs, a rise to 140 lbs, then another drop to 111.5 lbs, with the resident remaining at about 115 lbs thereafter. Although a later nutrition note identified an unplanned weight loss from 140 lbs to 111 lbs, there was no documentation that the earlier mid-August weight fluctuations were investigated, re-weighed for accuracy, or addressed with interventions. The Dietitian stated she began covering the facility after September 2025 and could not say what was wrong with the weights, but acknowledged that significant weight changes should be addressed with interventions. For Resident #143, the record showed a weight of 147 lbs on 1/22/26 and 132.4 lbs on 2/08/26 after a hospitalization, representing a 14.6 lb, 9.9% loss in 17 days. A nutrition assessment was completed the next day, but there was no evidence that the physician or provider was notified of the significant weight loss. The Dietitian confirmed that weight loss upon re-admission is still considered a significant change and stated that nursing is responsible for reporting weight changes to providers and family, but could not confirm that the change was reported. The DON later validated the findings and the lack of documented communication regarding the weight changes.
Failure to Provide Ordered Oxygen Therapy and Equipment Labeling
Penalty
Summary
The facility failed to provide necessary respiratory care services for three residents receiving oxygen therapy. Resident #1 was observed in bed receiving oxygen via nasal cannula, and both the tubing and humidifier bottle were unlabeled. The resident’s physician orders required continuous oxygen at 3-5 liters per minute via nasal cannula to keep saturation above 90% and required oxygen tubing changes weekly on the night shift every Sunday. Resident #3 was also observed receiving oxygen with unlabeled tubing, and the physician orders required 2 liters via nasal cannula for respiratory failure, with oxygen tubing to be checked and changed weekly and as needed, dated, and changed per protocol. A facility policy dated 1/29/24 required tubing and masks to be changed weekly and as needed. Resident #171 was observed receiving oxygen via nasal cannula at 2.5 liters per minute, although the medical record showed an order for 2 liters per minute. A later observation showed the resident still receiving 2.5 liters per minute. The charge nurse stated the resident was on 2 liters but that staff sometimes increased it to 2.5-3 liters if the resident removed the cannula and oxygen saturation decreased, and acknowledged there was no order for that practice. The resident’s record also showed no care plan for oxygen administration. The DON acknowledged that there should have been a care plan and that the oxygen setting should have been set at what was ordered.
Incomplete GNA Competency Validation
Penalty
Summary
The facility failed to ensure that newly hired Geriatric Nursing Assistants (GNAs) demonstrated competency in essential skills and techniques before providing resident care. During the recertification/complaint survey, the surveyor reviewed employee files for four randomly selected GNAs and found that each of the four files contained incomplete skills validation documentation. The missing documentation included items such as cleaning and disinfecting equipment, Transmission-Based Precautions, shower stretcher use, hearing aids, height and weight measurement, meal services, falls, nail care, oral care, transfers, vital signs, orthotic devices, oxygen, restraints, scheduled activities, shaving, and thickened liquids. The Skills Validation Records for Staff #11, #12, #13, and #14 were signed, but large portions of the required competency sections were left blank or incomplete. The Director of Nursing stated that GNA skills must be verified during new-hire training and that training should be completed before they begin work. After reviewing the files with the surveyor, the DON confirmed that the competencies were not fully documented and stated that no additional documentation existed to show that the GNAs' skills were verified before they began providing resident care.
Failure to Document and Address Behavioral Health Symptoms
Penalty
Summary
The facility failed to identify and provide appropriate behavioral health care and services to assist one resident in attaining the highest practicable mental health well-being. During an initial tour, the resident was observed screaming, yelling, and crying in the room, and a nursing staff member stated the resident had psychological issues. A family member reported the resident had no prior history of dementia or mental health issues and stated that after a knee fracture related to age and bone fragility, facility staff told them the screaming and crying were due to pain. Record review showed an initial psychological consultation had been completed months earlier, when the resident was identified as stable with no evidence of self-injurious behavior or psychosis. A later psychiatric NP note documented evaluation for visual hallucinations and verbal outbursts and ordered new medication, but the medical record contained no documentation of hallucinations or verbal outbursts before that evaluation. A unit manager stated the resident’s verbal outbursts began about three weeks earlier and that staff initially thought the behavior was due to knee pain, but the surveyor found no documentation of those unusual behaviors or any attempted interventions in the record; the DON later validated the findings.
Delayed Response to Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review recommendations were addressed in a timely manner for multiple residents. The report states that the facility did not respond promptly to consulting pharmacist recommendations for 3 of 5 residents reviewed for unnecessary medications during the recertification survey, despite a policy requiring monthly review of each resident’s drug regimen and physician review and signature of identified irregularities within 30 days of receipt. For one resident, the medical record showed clopidogrel ordered for CVA and Humalog sliding scale insulin ordered for diabetes mellitus. A pharmacy review recommended increasing the basal insulin dose to reduce reliance on sliding scale insulin, but the MAR showed insulin continued to be administered until the order was discontinued months later, and the physician signature documenting discontinuation was not obtained until about 5 months after the recommendation. Another pharmacy review recommended placing an adverse reaction monitoring order for clopidogrel, but the physician did not address the recommendation until 26 days later, and the monitoring was never implemented. For another resident, the record showed tizanidine 2 mg PRN for muscle spasm. The pharmacist recommended discontinuing the PRN order or limiting it to 14 days per federal psychotropic medication guidelines, but although the physician ordered discontinuation, the order remained active and the resident continued to receive the medication 37 times over several months. For a third resident, the pharmacist repeatedly noted that risperidone was being given without a documented allowable diagnosis; the resident’s record showed active risperidone orders and administration twice daily, and the DON stated that schizophrenia could not be listed until after a psychologist assessment. The record later showed a psychological assessment diagnosing schizophreniform disorder, and the DON acknowledged that the risperidone order had been discontinued and rewritten with schizophrenia as the indication for use.
Medication Administration Errors During PEG-Tube Medication Pass
Penalty
Summary
The facility failed to keep the medication error rate below 5% during a medication observation task, with 2 of 26 medication administration opportunities resulting in errors for a rate of 7.69%. During observation on 02/27/2026, an LPN administered acetaminophen 500 mg crushed via a gastric feeding tube to Resident #87, but the resident's order and MAR showed acetaminophen 325 mg, 2 tablets orally. The LPN stated she did not know why she thought she saw 500 mg on the resident's order. In the same observation, the LPN administered a multivitamin tablet via gastric tube, while the resident's medication order called for Multi-vitamin Liquid 15 mL via PEG-tube once daily. The report states that the medication was not administered in the correct dosage form as prescribed.
Unsecured and Improperly Stored Resident Medication
Penalty
Summary
Medication storage was not maintained in a locked compartment under proper temperature controls when a prescribed skin cream for Resident #172 was observed unattended on the resident’s window ledge during the initial tour of the facility. The medication container was labeled for Resident #172 and included instructions to refrigerate the medication. During an interview, an LPN stated that staff had recently provided personal care to the resident, explaining why the medication was at bedside. A review of the resident’s Treatment Administration Record showed an order for Greers [NAME] Cream to be applied topically to the perineal area twice daily for erythema interigo. The DON was later informed of the surveyor’s findings and acknowledged the concern.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable and served at a safe, appetizing temperature. A resident complained that hot foods were usually served cold. During a lunch tray line observation, the surveyor requested the Certified Dietary Manager to include a tray on the first cart going to the unit. The cart left the kitchen at 12:26 PM and arrived on the unit at 12:28 PM, but there was a seven-minute delay before staff began distributing trays, and the final tray was not served until 12:44 PM. The Dietary Manager tested the food on the observed tray and recorded temperatures of 140 F for fried shrimp, 134 F for French fries, and 86 F for coleslaw. The Certified Dietary Manager confirmed the facility standard was 135 F or above for hot items and 41 F or below for cold items.
Therapeutic diet not ordered for resident with ESRD and diabetes
Penalty
Summary
The facility failed to ensure that a therapeutic diet was prescribed for a resident with Diabetes and End-Stage Renal Disease (ESRD). Resident #57 told the surveyor that the meals provided did not match the resident’s medical conditions and stated that, because of a pending kidney transplant and the need for a controlled diet for diabetes and ESRD, the resident should not have been served foods such as spinach, bananas, and soda. The resident’s documented diet order was a heart-healthy diabetic diet with regular texture and thin liquids. Record review showed that a nurse documented concerns from the resident and the resident’s daughter about daily meals and noted that the resident could not eat certain foods because of the ESRD diagnosis, but there was no evidence that the diet order was revised. The Certified Dietary Manager stated the kitchen was aware of the resident’s preferences and that restricted foods were written in personal notes shared with the cook. The Dietitian confirmed the facility offered renal diets and stated that, based on the resident’s diagnoses, the order should have been a renal diet. The DON later validated the findings.
Failure to Use PPE During PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure staff donned appropriate PPE for Enhanced Barrier Precautions during medication administration for Resident #87. Resident #87 had an EBP sign posted near the room door, and the resident’s medication was administered through a PEG tube. During observation of the medication administration task, LPN #31 was seen completing the process without using the required gown and gloves. The surveyor observed the room door with the EBP sign posted at 10:55 AM on 02/27/2026. At 10:57 AM, LPN #31 explained that the resident’s medication was given through a PEG tube, which had the potential to introduce harmful bacteria to the resident. The surveyor continued to observe the medication administration and noted that the LPN did not use appropriate PPE during the task. Later that day, the DON was informed that LPN #31 had failed to use appropriate PPE during medication administration via gastric tube, and the DON verbally acknowledged the concern.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R44, using a mechanical lift, resulting in a right femur fracture. R44, who was cognitively intact and required substantial assistance with transfers, was struck by a Hoyer lift, leading to the fracture. Despite R44 expressing fear of the lift due to a previous incident, this concern was not adequately addressed or documented by the staff. The incident was not reported to the Director of Nursing (DON) or the Administrator, and no investigation was initiated at the time of the incident. The facility's policies required that any unusual occurrences be reported and documented, and that mechanical lifts be used by two trained staff members. However, these protocols were not followed. LPN1, who was informed of the incident by a Geriatric Nursing Assistant (GNA), failed to report the incident or document an assessment of R44. The facility's records showed no evidence of an assessment or investigation into the incident, and the DON was unaware of the fracture until much later. Interviews with staff revealed a lack of communication and documentation regarding the incident. The Nurse Practitioner (NP) and other staff members did not report the fracture to the administration, and the facility did not conduct a root cause analysis. Additionally, the facility's training on mechanical lifts was insufficient, as it was not included in annual competency checks, contributing to the unsafe transfer and subsequent injury of R44.
Removal Plan
- Training on the use of mechanical lifts
- Reporting accidents/incidents to the Administrator or Director of Nursing
- Ongoing monitoring and evaluation
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature for five residents reviewed for food palatability. This deficiency was identified through observations, interviews, and reviews of Resident Council Minutes and facility policies. The facility's policy required meals to be delivered within 30 minutes to maintain food quality and temperature, but residents consistently reported issues with food being cold, overcooked, or unappetizing. Specific complaints included cold eggs, burnt toast, and hard waffles, with residents expressing dissatisfaction with the lack of variety in meal alternatives. Observations and interviews revealed systemic issues in meal delivery, including inadequate equipment and staffing. The Dietary Manager noted that the heating machine lacked necessary pellets to keep food warm, and the Unit Manager reported insufficient staff to promptly serve meals. This resulted in delays, with trays observed sitting on serving carts for extended periods before being served to residents. The Administrator acknowledged the expectation for meals to be served promptly but noted that new equipment to maintain food temperature had not yet been implemented.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during meals. The resident, who was severely cognitively impaired and had a history of depression and cerebrovascular accident, was observed calling for help while lying in bed with a meal tray in front of them. The resident's meal tray was placed next to a large tube of A&D Medicated Ointment, which is used for incontinent care, and should not have been left near food. Staff confirmed that the ointment should not be at the bedside, especially near food, and removed it. During the meal, the Unit Manager stood over the resident while attempting to feed them, which is against the facility's practice of sitting down and making eye contact with residents during feeding. The Unit Manager did not offer the resident an alternate meal when the resident repeatedly spat out the food, despite the availability of alternate pureed meal options. The resident expressed a preference for a pureed hamburger, which was eventually provided after the Assistant Dietary Manager confirmed the availability of alternate meals. Interviews with various staff members, including a Certified Medicine Aide, Geriatric Nursing Assistant, and Licensed Practical Nurse, reiterated the importance of sitting down to feed residents and not leaving ointments near food. The facility's Administrator and Assistant Director of Nursing also confirmed these practices, emphasizing the need to offer meal alternatives and maintain dignity during feeding.
Improper Resident Discharge Without Adequate Documentation
Penalty
Summary
The facility failed to permit a resident to stay in their facility without adequate reason and documentation, leading to a deficiency. The resident, admitted for subacute rehabilitation services, expressed a desire to return home, as documented in a psychological assessment and care plan note. Despite having the capacity to make decisions, the resident was issued a Notice of Medicare Non-Coverage and subsequently transferred to another facility for assisted living, although the discharge summary inaccurately stated the resident was transferred to an assisted living facility. The resident's representative was not informed of the discharge until after it occurred, and the resident was confused about the transfer, having wanted to return home. The facility's Director of Social Services reported that the resident was not able to discharge safely home due to a lack of community support and unwillingness to sign over assets for Medicaid application. However, there was no documentation of a resident-initiated discharge, agreement with the discharge, or a transfer notice. Additionally, the surveyor found no discharge care plan in the electronic medical record, despite claims from the Director of Social Services that one had been initiated. The Discharge Planner confirmed that the resident had expressed a desire to go home, not to another facility.
Failure to Provide 30-Day Transfer Notice
Penalty
Summary
The facility failed to issue a 30-day transfer notice to a resident prior to transferring them to another facility. This deficiency was identified during a recertification/complaint survey for one of the two residents reviewed for discharge. A record review revealed that the resident had been issued a Notice of Medicare Non-Coverage (NOMNC) on September 6, 2024, indicating that their benefits would end on September 11, 2024. The resident was subsequently discharged to another facility on September 10, 2024, without documentation of the resident initiating the transfer, agreeing to it, or receiving a 30-day discharge/transfer notice. Interviews with the Director of Social Services and the Discharge Planner confirmed that the discharge was not initiated by the resident, who had expressed a desire to return home rather than be transferred to another facility. The Nursing Home Administrator was made aware of these concerns during the survey.
Failure to Initiate Discharge Care Plan for Resident
Penalty
Summary
The facility failed to provide adequate discharge planning for a resident, identified as Resident #829, during a recertification/complaint survey. The deficiency was identified when a complaint was reviewed, revealing concerns about the facility's failure to provide a discharge date for the resident. The medical record review showed that a discharge planning progress note was written by the Discharge Planner, indicating the plan for the resident to return home upon discharge. However, despite the resident being admitted for aftercare of a right femoral fracture, high blood pressure, and cardiomyopathy, and being ordered occupational and physical therapy, the facility did not initiate a discharge care plan. This care plan is essential for setting discharge goals and implementing interventions to help the resident achieve those goals. Interviews with facility staff further highlighted the deficiency. The Discharge Planner confirmed that while she discussed discharge and insurance benefits with the resident, she was not responsible for initiating the discharge care plan. The Director of Social Services, who was not employed at the facility at the time of the resident's admission, confirmed that a discharge care plan should have been initiated upon admission but was not. These findings were reviewed with the Nursing Home Administrator, confirming the lack of a discharge care plan for the resident.
Inadequate Pain Management and Monitoring
Penalty
Summary
The facility failed to provide adequate monitoring of a resident's pain, resulting in delayed treatment for a fractured right ankle. The deficiency was identified during a recertification/complaint survey for one of the 39 residents reviewed. The Medication Administration Record (MAR) for the resident did not include a space for nursing staff to document the resident's pain score at the time of assessment, which is crucial for monitoring and managing pain effectively. This lack of documentation prevented the healthcare team from accurately assessing the resident's pain and potentially contributed to the delay in identifying and treating the fracture. The resident in question was admitted with long and short-term memory issues and was non-verbal, necessitating the use of an alternative pain scale. However, the facility did not provide such a tool, which should have included observations of facial grimaces and behavior to assess pain levels. Interviews with the Director of Nursing and the Nurse Practitioner confirmed the absence of an alternative pain scale and the necessity for one, given the resident's inability to verbalize pain. This oversight in pain management documentation and assessment led to the resident's pain being inadequately monitored and treated.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 9.68% error rate during a medication pass observation. This deficiency was identified through observations, interviews, and record reviews. Specifically, three errors were observed out of 31 opportunities, which had the potential to impact two residents. The facility's policy on medication administration, which includes reviewing the five rights of medication administration, was not adhered to by the staff. One resident, who was readmitted with a diagnosis of systemic lupus erythematosus, was prescribed Plaquenil to be taken in the evening. However, a Certified Medicine Assistant administered the medication without confirming the correct timing or understanding the medication's purpose. Another resident, with diagnoses including diabetes mellitus and gastric protection, was prescribed sucralfate to be taken on an empty stomach and insulin glargine at bedtime. The Licensed Practical Nurse administered sucralfate after the resident had eaten and gave insulin in the morning instead of at bedtime, indicating a lack of awareness of the specific administration instructions.
Failure to Offer Alternate Meal to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide an alternate meal to a severely cognitively impaired resident, identified as R23, during a meal observation. R23, who had a BIMS score of five out of 15, indicating severe cognitive impairment, was observed spitting out each bite of the pureed meal being fed by the Unit Manager. Despite the resident's clear dislike for the meal, the Unit Manager did not offer an alternate meal, as per the facility's policy, which requires nursing staff to offer alternatives if a resident does not eat at least 25% of their meal or refuses food. The Assistant Dietary Manager later confirmed that there were alternate pureed meal options available, such as a pureed hamburger or hotdog, which R23 expressed a preference for. The resident eventually received the alternate meal and expressed satisfaction with it. Interviews with staff, including a Geriatric Nursing Assistant and the facility's Administrator, confirmed that alternate meals should be offered to residents who do not like their food, highlighting a lapse in adherence to the facility's meal delivery policy.
Inadequate PPE Use and Medication Handling
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) during wound care for a resident on Enhanced Barrier Precautions (EBP). The resident, who had a history of clostridioides difficile colitis and a nephrostomy tube, required the use of gown and gloves during high-contact care activities. However, during an observation, neither the Licensed Practical Nurse (LPN) nor the Geriatric Nursing Assistant (GNA) wore gowns while performing wound care. Both staff members confirmed the omission, and the facility's Infection Preventionist acknowledged that gowns should have been worn. Additionally, during a medication administration, an LPN was observed dropping a pill onto the medication cart and then placing it back into the medication cup before administering it to a resident. The LPN confirmed the action, and the Director of Nursing stated that dropped medications should be disposed of and replaced. The Infection Preventionist also confirmed that medications dropped during administration should not be given to residents.
Failure to Properly Review and Document Admission Agreements
Penalty
Summary
The facility failed to provide and review admission agreements with the appropriate resident or representative for two residents during a recertification/complaint survey. The first resident, admitted in early February 2024, was assessed with a Brief Interview of Mental Status (BIMS) score of '00', indicating severe cognitive impairment. Despite having an identified representative, the admission contract was electronically signed with initials that did not match either the resident or the representative. The Admissions Director was unable to verify the signature, and the employee responsible for completing the form was no longer employed at the facility. The second resident was noted to be unable to participate in the admission assessment due to mental status and was only oriented to 'self'. The admission contract contained neatly entered initials on one page and an illegible signature on another, which did not match, raising concerns about the validity of the signature. The resident was not identified as their own representative, and the person who should have received the admission contract was not properly documented. The discrepancies were confirmed by the Administrator and Admissions Director, and the responsible employee was no longer with the facility.
Incorrect Surrogate Decision Making on MOLST Form
Penalty
Summary
The facility failed to ensure the correct person was identified to make medical treatment decisions on the Maryland Order for Life Sustaining Treatment (MOLST) form for Resident #818. Upon admission in October 2022, the resident's MOLST form indicated a full code status, reflecting the resident's request for cardiopulmonary resuscitation (CPR). However, a subsequent MOLST form was completed, changing the resident's status to 'do not resuscitate/do not intubate' based on the surrogate decision maker's choice, despite the resident's initial wishes. The change was documented as having been discussed with the resident and family, although the resident was certified incapable of making medical decisions. The facility social worker acknowledged the inappropriate change during an interview.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident 18 within the required two-hour timeframe and did not submit the investigative results within five working days to the State Survey Agency (SSA). Resident 18, who was admitted with a right femur fracture and cognitive communication deficit, was found to have a dislocated right hip with comminuted fracturing of the proximal right femur. The facility became aware of this injury on July 23, 2024, but did not report it to the SSA until July 24, 2024, at 6:00 PM, which was one day after the injury was discovered. Furthermore, the follow-up investigation report was submitted eight days after the facility learned of the injury, exceeding the five-day requirement. In another instance, the facility did not report an injury of unknown origin for Resident 807 to the state agency. On April 3, 2023, a nurse observed a dark discoloration on the resident's right upper arm, but the resident could not explain how it occurred. The Director of Nursing (DON) later provided investigation documents, including staff statements and a root cause analysis, but there was no evidence that the injury was reported to the state agency. The DON explained that the injury was not reported because the facility believed they knew how it occurred, based on a Geriatric Nursing Assistant's (GNA) statement about the resident's behavior. The Director of Nursing confirmed that the initial and five-day summary reports for Resident 18 were submitted late, and the injury for Resident 807 was not reported at all. These failures to report injuries of unknown origin in a timely manner are contrary to the facility's policy and regulatory requirements, which mandate immediate reporting to the state agency within two hours for serious injuries and within five days for investigative results.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for two residents during a recertification/complaint survey. For one resident, who was admitted with a right femur fracture and cognitive impairments, an x-ray revealed a dislocated right hip with comminuted fracturing of the proximal right femur. Despite the severity of the injury, the facility's investigation did not include interviews with other residents to determine if there was any abusive or neglectful treatment by staff. The Director of Nursing confirmed that resident interviews were not conducted as part of the investigation. Similarly, another resident sustained a fracture to the right ankle, but the facility was unable to determine the cause or timing of the injury. The investigation into this incident also lacked interviews with other residents to assess potential abuse or neglect by facility staff. The Administrator confirmed that the investigation did not include resident interviews to rule out staff misconduct, indicating a failure to adhere to the facility's policy on thoroughly investigating injuries of unknown origin.
Failure to Follow Physician Orders and Document Care
Penalty
Summary
The facility staff failed to provide treatment and care in accordance with professional standards for two residents during a recertification/complaint survey. For one resident, the medical record indicated a change in condition with swelling in the right lower jaw, prompting a physician's order for a dental consult. However, there was no documentation of the dental consult being obtained, and the Director of Nursing (DON) could not provide evidence of the consult or explain the lack of documentation. Additionally, the same resident had orders for behavior monitoring, but the Medication Administration Records (MAR) lacked detailed documentation of observed behaviors, interventions, and outcomes as required by the physician's order. The DON acknowledged a systems error but could not clarify how nurses were expected to document behaviors under these circumstances. For another resident, the facility failed to follow a physician's order to obtain and send a stool sample for laboratory analysis to investigate the cause of constipation. The electronic medical record review revealed no evidence of the stool sample being collected and sent for analysis, which was confirmed by the DON. These deficiencies highlight lapses in following physician orders and maintaining accurate documentation, impacting the quality of care provided to the residents.
Failure to Follow Up on Recommended Vascular Consult
Penalty
Summary
The facility staff failed to follow up with outside resources for the care of a resident, leading to a deficiency identified during a recertification/complaint survey. The resident, who had multiple pressure ulcers and deep tissue injuries of the left foot, was assessed by the facility wound physician. The wound care team recommended a vascular consult with a doppler exam for further evaluation of the resident's vascular condition. Despite the facility staff being aware of this recommendation, the necessary vascular consult and doppler study were not completed. This oversight was confirmed during a review of the resident's medical record and interviews with the facility's Director of Nursing and Consultant Nurse.
Inaccurate Documentation of Stool Specimen Collection
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #513, as evidenced during a revisit survey. On January 8, 2025, a review of the resident's treatment administration record (TAR) showed that a stool specimen collection task was marked as completed on January 3, 2025, by LPN #13. However, an interview with the Nursing Home Administrator on January 9, 2025, revealed that the stool specimen was never collected because the resident did not have a bowel movement. This discrepancy was confirmed by the Regional Clinical Nurse, who stated that a check sign on the TAR indicates task completion, highlighting that LPN #13 inaccurately documented the task as completed.
Outdated Facility Assessment and Resident Data
Penalty
Summary
The facility failed to update its Facility Assessment annually, which is necessary to ensure that the resources required to care for residents are accurately determined. The most recent update to the Facility Assessment was on February 6, 2023, and it did not include current staff names or accurate resident assessments. The resident data included in the assessment was outdated, reflecting Minimum Data Set (MDS) data from January 1, 2022, to January 30, 2022. This oversight could negatively impact all 151 residents by not adequately assessing and determining their current needs. During an interview, the Administrator and the Regional Director of Operations acknowledged the outdated nature of the Facility Assessment and the necessity for current resident information to provide appropriate care.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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