Devlin Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cumberland, Maryland.
- Location
- 10301 North East Christie Road, Cumberland, Maryland 21502
- CMS Provider Number
- 215244
- Inspections on file
- 16
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Devlin Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with pancreatic cancer and cirrhosis, including ascites and esophageal varices, had labs ordered that showed a significantly elevated ammonia level. The PA reviewed the abnormal result, documented "no new orders," and did not enter any treatment, monitoring parameters, or the intended order to recheck the ammonia level, nor a progress note explaining the assessment. Days later, the resident developed altered mental status and abdominal pain, and was sent to the ED at the family’s insistence, where an even higher ammonia level was found and hepatic encephalopathy was diagnosed, requiring treatment with lactulose and a multi-day hospitalization.
A cognitively impaired resident who depended on staff for most ADLs was being transferred with a mechanical lift when a GNA reported being hit by the resident and responded by cursing at and verbally degrading the resident, including making offensive remarks and threatening to withhold treats. Another staff member nearby overheard the GNA loudly say, “Don’t fucking hit me,” but did not report the incident because she believed the comment was directed at another staff member rather than the resident, resulting in unreported verbal abuse.
Staff failed to timely report a witnessed allegation of verbal abuse to the State Agency. A GNA verbally abused a resident during an evening shift, and on‑duty staff who observed the incident did not report it when it occurred. The DON later learned of the allegation the following morning and submitted the report to the State Agency several hours after that notification, rather than within 2 hours of the actual incident. The DON reported she believed the reporting timeframe began when she was informed of the allegation, leading to noncompliance with required abuse reporting timelines.
Staff failed to immediately remove a GNA from resident care after verbally abusing a cognitively impaired resident with dementia. During an evening shift, the GNA used profane language toward the resident while providing care, but other staff present did not recognize or report the incident as abuse at the time. The DON was not informed until the following morning, and staffing records confirmed that the GNA continued working for about 10 hours with vulnerable residents after the incident occurred.
Facility staff failed to ensure that a resident with pancreatic cancer and a prior Whipple procedure consistently received prescribed Creon with meals, resulting in multiple missed doses when the medication was not available. The MAR documented missed administrations due to the drug not being in stock or on order, and pharmacy records showed that refills were sent only after the supply had already run out. The DON knew the resident required Creon and that it was a special‑order medication but had no process to secure it before admission or to reorder in time, and staff instead contacted the family to bring medication from home. The facility’s medication ordering policy lacked provisions for special‑order drugs and there was no documentation that the hospital had instructed the family to supply the medication.
The facility failed to develop and implement a QAPI program because it did not have a written QAPI plan to guide performance improvement activities. The QA coordinator, DON, and NHA were unaware of the regulatory requirement, and the QA coordinator reported she had no established plan to guide QAA committee meetings or oversight duties.
Incomplete QAPI Program and Physician Visit Review Deficiency: The facility failed to maintain an effective QAPI program with clear policies, procedures, benchmarks, and communication methods, and it remained out of compliance with physician visit requirements. For a resident with duodenal ulcers, NPO status, and TPN, discharge medications including a PPI and GI protectant were not ordered, and the physician note did not reflect awareness that the medications were missing or that the resident had no bowel sounds on admission. Interviews showed confusion about the discharge summary, no auditing of physician notes by the DON, and a mismatch between the written QAPI policy and how the committee actually operated.
Two residents experienced delays in assessment and treatment after changes in condition were not promptly addressed by nursing staff. In one case, a resident sustained a hand laceration during care, which was not immediately assessed or documented by the LPN after being reported by aides, and was only discovered by family later. In another case, a resident developed facial bruising and a hematoma that was reported to nurses but not assessed or reported to a provider until the following day, resulting in delayed medical evaluation. Both incidents involved lapses in communication and failure to follow facility policy for timely intervention and documentation.
A resident with intact cognition and multiple medical conditions reported missing money to staff, who searched the room and provided a lock box but could not confirm the resident ever had the funds. The incident was initially treated as a grievance and not reported to the state agency as required. The allegation was only reported months later after being raised again, resulting in a late submission of the required investigation report.
A facility failed to include anticoagulant medication in a resident's care plan. The resident, with moderate decision-making impairment and conditions like paroxysmal atrial fibrillation, was prescribed Eliquis. However, the care plan lacked focus, goals, or interventions for the medication. Interviews with the MDS Coordinator and DON confirmed the omission, despite facility policy requiring comprehensive care plans.
Failure to Act on Elevated Ammonia Level Resulting in Hospitalization
Penalty
Summary
Facility staff failed to ensure that a resident’s abnormal laboratory result was appropriately evaluated and addressed by the practitioner. The resident had diagnoses including pancreatic cancer and cirrhosis of the liver with ascites and esophageal varices. A progress note indicated that a cancer center appointment was cancelled and that the NP’s order for labs, including an ammonia level, should be followed. The resident’s ammonia level, drawn the following day, was 76 (reference range 9–35) and marked as high. The result was circled, annotated “NNO” (no new orders), and noted to have no previous ammonia level for comparison, and was signed by PA #1. There were no new treatment orders, no monitoring orders, and no corresponding progress note documenting assessment or clinical reasoning in the medical record related to this abnormal result. Subsequently, the resident experienced a change in mental status and abdominal pain. A progress note documented that the resident was sent to the ED for further evaluation after the resident’s family insisted on transfer. In the ED, the resident was found to have an ammonia level of 180 (reference range 9–35) and was diagnosed with hepatic encephalopathy. The resident was treated with lactulose and remained hospitalized for six days before discharge. The attending physician/Medical Director later stated that the resident had an elevated ammonia level that PA #1 had missed and acknowledged that the family was not happy with the situation. During interview, PA #1 confirmed that she had reviewed the elevated ammonia level and had not written any orders. She stated that because the resident did not have a history of hepatic encephalopathy and nursing staff had not reported a change in mental status, she decided not to treat the resident and did not write monitoring orders, believing such monitoring to be part of routine nursing care. She also reported that she had intended to recheck the ammonia level in a couple of days but failed to enter the order into the medical record. This failure to order treatment or monitoring, and the omission of the planned repeat ammonia level, occurred despite the clearly abnormal lab value and contributed to the resident’s subsequent hospitalization for hepatic encephalopathy.
Failure to Protect Cognitively Impaired Resident From Verbal Abuse by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by staff. Record review showed that the resident had severe cognitive impairment, unclear speech, intermittent understanding, and dependence on staff for most ADLs. During an evening shift, a GNA was assisting another GNA with transferring the resident using a mechanical lift when the resident reportedly hit the GNA. Witness accounts documented that the GNA responded by cursing, including statements such as “don’t fucking hit me,” and later, in reference to the resident, “fucked [his/her] ass straight up and [his/her] is a fucking retarded gimp,” and that the resident “won’t be getting any more ice cream” from her. Another staff member heard the raised voice and profanity but could not see into the room because the door was closed. The facility’s investigation file and interviews further showed that the GNA admitted to holding the resident’s arm down after being hit and later admitted to cursing at the resident. A CMA who was near the room at the time heard the GNA say, “Don’t fucking hit me,” but did not report the incident because she believed the comment was directed at the other GNA rather than the resident. The DON’s interviews with involved staff confirmed that the GNA’s voice was raised during the incident and that abusive language was used toward the resident, establishing that the resident was subjected to verbal abuse and that at least one staff member failed to recognize and report the allegation of abuse at the time it occurred.
Failure to Timely Report Witnessed Verbal Abuse Allegation to State Agency
Penalty
Summary
Staff failed to recognize and report an allegation of verbal abuse to the State Agency within the required timeframe. Record review showed that a Geriatric Nursing Assistant (GNA) verbally abused Resident #6 on 1/20/26 during the evening shift, between approximately 8:00 PM and 8:30 PM, and that this abuse was witnessed by facility staff who did not report the incident at the time it occurred. The facility’s investigation file for facility reported incident #2726923 documented that the DON became aware of the allegation of abuse on 1/21/26 at 9:32 AM, and an email confirmation showed the report was sent to the State Agency on 1/21/26 at 12:42 PM. During interview, Certified Medicine Aide (CMA) #5 confirmed she was present when the verbal abuse occurred on the evening of 1/20/26. The DON stated she believed the 2‑hour reporting timeframe began when she was notified of the allegation, rather than from the time the abuse occurred, resulting in the allegation not being reported within the required timeframe. This deficiency was identified for 1 of 4 facility‑reported incidents reviewed and is cross‑referenced to F600 and F610.
Failure to Remove Alleged Abusive Staff Member From Resident Care
Penalty
Summary
Facility staff failed to ensure that a staff member observed verbally abusing a resident was immediately removed from access to vulnerable residents. Record review showed that Resident #6 had dementia and was severely cognitively impaired per an MDS with an assessment reference date of 12/18/25. The facility’s investigation file for a reported incident indicated that on 1/20/26 during the evening shift, GNA #3 verbally abused Resident #6 while GNA #3 and GNA #4 were putting the resident back to bed, stating, “Do not fucking hit me.” Staff did not recognize this as abuse at the time, and it was not reported to the DON until 1/21/26 at 9:32 AM. Staff assignment sheets and time punches confirmed that GNA #3 worked the evening shift starting at 2:30 PM on 1/20/26 and continued working until 6:30 AM on 1/21/26, resulting in approximately 10 hours of continued work with vulnerable residents after the verbal abuse occurred. A CMA who was present confirmed the time frame of the incident as between 8:00 PM and 8:30 PM on 1/20/26. These findings show that the facility did not promptly remove the alleged perpetrator from resident care or immediately report the abuse to appropriate leadership after it occurred.
Failure to Ensure Availability of Essential Pancreatic Enzyme Medication
Penalty
Summary
Facility staff failed to ensure that a resident with pancreatic cancer who had undergone a Whipple procedure consistently received the prescribed pancreatic enzyme medication, Creon, upon admission and throughout the stay. The hospital discharge summary documented the need for Creon with meals to assist with digestion and nutrient absorption, and the resident’s orders specified Creon capsules three times daily. Review of the MAR showed multiple missed doses on specific dates when the medication was not administered because it was not available, with nurses documenting that the drug was not available from the pharmacy, was on order, or was pending physician evaluation. On the day of admission, the assigned RN did not administer Creon because it had not been ordered from the pharmacy and documented the missed dose accordingly. Pharmacy dispensing records showed that Creon was shipped in 100‑capsule quantities on three separate dates, which coincided with documented missed doses when the facility allowed the supply to run out before refills arrived. The DON acknowledged awareness prior to admission that the resident required Creon and its importance with each meal, yet there was no process in place to ensure the medication was available at admission or to prevent running out between refills. The DON reported that staff asked the family to provide the medication from home and that special‑order medications took longer to obtain because they required her signature and were not stocked at the pharmacy. The facility’s policy on ordering and receiving medications lacked an implementation date and did not include provisions for special‑order medications, and there was no documentation that the hospital case manager had instructed the family to bring the medication at admission.
Missing Written QAPI Plan
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program because it did not have a written QAPI plan to guide its efforts in maintaining acceptable levels of performance and continual improvement. During review of the QAPI program information provided by the QA coordinator, surveyors did not find a QAPI plan. The DON and QA coordinator stated they were unaware of the regulatory requirements for a QAPI plan and were unsure whether the facility had one. The DON said she would need to contact corporate consultants to determine whether a plan existed, and the QA coordinator reported she was responsible for overseeing the program and conducting QAA committee meetings but had no established QAPI plan to guide those duties. In a later interview, the DON stated that a corporate consultant told her a QAPI plan was not required to be written out, then acknowledged after review of the regulation that the facility had no QAPI plan in writing. The NHA also stated he was unaware of the required QAPI plan.
Incomplete QAPI Program and Physician Visit Review Deficiency
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program, including the development and implementation of policies and procedures for the program. During the revisit survey, the facility was found to still be out of compliance with CMS regulation 483.30(b) related to physician visits, and the deficiency was associated with harm to a resident. The survey also identified that the facility’s QAPI policies and procedures were incomplete, lacking dates of completion, implementation, and last review, and did not clearly define the committee’s feedback mechanisms, benchmarks, responsible role for data collection and analysis, or communication methods for QAPI indicators, initiatives, strategies, and results. For Resident #1, a hospital discharge summary documented multiple duodenal ulcers, NPO status, TPN, and discharge medications that included a proton pump inhibitor and a gastrointestinal protectant. A review of the resident’s physician orders showed those medications had not been ordered. There were no notes explaining why the medications were not continued by the admitting RN, and no orders or notes entered by the PA who reviewed the discharge with the RN. The resident’s history and physical by Physician #6 later stated the full plan of care, including medication orders, had been reviewed and indicated the resident was to continue the proton pump inhibitor and gastrointestinal protectant, but the note did not show awareness that the resident had no bowel sounds on admission, had reported not being on oral medications in the hospital, or that the discharge medications had not been ordered. Interviews confirmed confusion about the discharge summary and that the resident was supposed to remain NPO until examined by the physician the next day, but this information was made part of the medical record. Physician #6 stated he thought the resident was on the medications as listed on the discharge summary and acknowledged it would have been his mistake if the medications were not entered or handwritten. The DON stated the facility was not auditing physician notes to ensure the full plan of care and medications were reviewed at each visit. The QA coordinator stated there were no established QAPI policies and procedures and that she relied on procedures from other facilities, while the NHA stated he participated in meetings but could not explain his role beyond monitoring the meeting and quality improvement. The facility’s written policy identified the NHA as chair of the committee, but the QA coordinator actually ran the meetings, and the policy did not match the facility’s practice.
Failure to Timely Assess and Intervene After Resident Change of Condition
Penalty
Summary
The facility failed to timely assess and implement interventions after a change of condition for two residents, resulting in delays in assessment and treatment. In the first case, a resident with severe cognitive impairment and dependence for activities of daily living sustained a deep laceration to the right hand during care when the resident grabbed a side rail while being turned. The incident was initially reported by the geriatric nursing assistants to an LPN, but there was no immediate nursing assessment or documentation. The injury was ultimately discovered by the resident's family, prompting a registered nurse to assess the wound and arrange for emergency care. Witness statements revealed that the LPN did not recall being informed of the injury, and there was a lack of timely follow-up and documentation as required by facility policy. In the second case, another resident with moderate cognitive impairment and a history of falls was observed with facial bruising and a hematoma by staff. The discoloration was reported to nurses at the station, but there was confusion among staff regarding who was responsible for assessing and reporting the injury. The assigned nurse did not document or report the injury, and no immediate assessment or notification to the medical provider occurred. The following day, the resident was found with more extensive bruising and swelling, at which point a full assessment was completed, and the resident was sent to the emergency room. Interviews with staff indicated that the initial report of the injury was not acted upon in a timely manner, and the required procedures for injuries of unknown origin were not followed. Both incidents demonstrate a failure to follow facility policy regarding timely assessment, documentation, and communication of changes in resident condition. Staff interviews revealed lapses in communication and uncertainty about responsibilities, resulting in delays in care and treatment for the affected residents. The deficiencies were identified through interviews, record reviews, and facility document reviews, which confirmed that the required interventions and notifications were not completed as specified in the facility's policies.
Failure to Timely Report Allegation of Misappropriation of Property
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of property to the state survey agency, as required by policy. A resident, who had a history of congestive heart failure, type II diabetes mellitus, and acute respiratory failure with hypoxia, reported missing money in January. The resident, who was cognitively intact, informed the social worker that $225 was missing from their belongings. Staff searched the resident's room and provided a lock box for valuables, but could not locate the money or confirm if the resident ever possessed the amount claimed. Despite the allegation being reported to multiple staff members, including a Geriatric Nursing Assistant and the Director of Nursing, the incident was not reported to the state agency at that time. The facility's policy required immediate reporting of any alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property. However, the staff treated the incident as a grievance rather than a reportable allegation because they could not verify the resident had the missing money. The allegation resurfaced in April, at which point the facility reported it to the state agency, several months after the initial report by the resident. The required 5-day investigation report was also submitted late, outside of the mandated timeframe. Interviews with staff revealed that the decision not to report the incident in January was based on the inability to substantiate the resident's claim. Staff, including the social worker and unit managers, stated that they did not observe the resident with the alleged sum and only reported the incident after it was brought up again months later. The administrator confirmed that the facility typically reported such allegations within two hours but, in this case, delayed reporting due to doubts about the validity of the claim.
Failure to Include Anticoagulant in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was receiving anticoagulant medication, specifically Eliquis. The resident, who was admitted with diagnoses including unspecified disorders of the brain and paroxysmal atrial fibrillation, was noted to have a moderately impaired decision-making ability. Despite the resident's condition and the physician's order for Eliquis, the care plan did not include any focus, measurable goals, or interventions related to the use of anticoagulant medication. Interviews with the MDS Coordinator and the Director of Nurses confirmed that the care plan should have included information about the anticoagulant medication. The MDS Coordinator stated that care plans are typically updated during each quarterly assessment, and acknowledged that the anticoagulant should have been included. The Director of Nurses also confirmed that the resident was receiving Eliquis and that this information should have been part of the care plan. The facility's policy requires the development of a comprehensive care plan that meets professional standards of quality care, which was not adhered to in this case.
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.
