Doctors Community Rehabilitation And Patient Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Lanham, Maryland.
- Location
- 6710 Mallery Drive, Lanham, Maryland 20706
- CMS Provider Number
- 215108
- Inspections on file
- 21
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Doctors Community Rehabilitation And Patient Care during CMS and state inspections, most recent first.
Facility staff failed to accurately code a resident’s fall on the quarterly MDS assessment. The resident had a documented fall resulting in a hematoma and was sent to the ER for evaluation, but this fall was not captured in Section J (falls) of the subsequent quarterly MDS. During an interview, the MDS Coordinator confirmed that the assessment, completed by another staff member, did not include the fall event.
A resident with a MOLST indicating full code status was found unresponsive without a palpable pulse, and staff initiated CPR and used an AED, which advised no shock. Instead of immediately activating EMS as required by the facility’s CPR policy and AHA guidelines, the nursing supervisor first called the resident’s representative to confirm continuation of full code status and then contacted the on-call provider, who instructed that 911 be called. EMS was not contacted until after these calls, and upon arrival found the resident in cardiac arrest with cold skin and signs of rigor mortis before pronouncing the resident deceased. Facility leadership confirmed that staff failed to call 911 prior to contacting the resident’s representative and provider, contrary to professional standards of practice.
Staff failed to follow physician medication orders and hold parameters for three residents. One resident with heart failure missed a scheduled dose of Lasix when the original dose was not resumed after a temporary increase. Another resident with a history of stroke and HTN received Amlodipine multiple times despite heart rates below the ordered hold parameter, with no documentation that the drug was held or the physician notified, contrary to the care plan requiring vital sign monitoring and reporting of abnormalities. A third resident with CHF and supraventricular tachycardia received Metoprolol on several occasions when SBP readings were below the ordered threshold, again without nursing documentation that the medication was held or the physician contacted.
A resident was not given their prescribed morning medications, including several critical drugs, due to a nurse's failure to administer and document them as required. The MAR lacked evidence of administration, and staff interviews confirmed the omission, with the DON substantiating the incident. The nurse assigned that day did not provide an explanation for the missed doses.
A resident was administered double doses of Synthroid for four days after a new order for an increased dose was added to the MAR without discontinuing the previous order. The error occurred when a nurse transcribed the new order but failed to remove the old one, resulting in both doses being given. The DON confirmed awareness of the incident and stated that staff are expected to review and discontinue outdated medication orders.
A resident did not receive the full number of physical therapy (PT) sessions as ordered, receiving only 15 out of 20 required sessions due to scheduling conflicts and misinterpretation of the therapy order by the rehab staff. The DON confirmed ongoing issues with missed therapy sessions.
Two residents experienced staff-to-resident abuse when a housekeeper used curse words and a threatening gesture toward one resident, and a GNA verbally abused another resident with derogatory language during care. Both incidents involved residents with significant medical and cognitive needs, and were confirmed by staff interviews and written statements, in violation of facility abuse prevention policies.
A resident experienced harm due to the facility's failure to clarify conflicting Vancomycin orders and monitor appropriate dosing. The discharge summary listed both once and twice daily dosages, but no clarification was documented. Random Vancomycin levels were obtained instead of trough levels, and high levels were not addressed by the nurse practitioners. This led to the resident being transferred to the hospital with Vancomycin toxicity and acute renal failure.
A facility failed to maintain the confidentiality of resident medical records when a laboratory log was left accessible on a nursing station countertop. The log contained sensitive information for several residents, including lab test schedules and requisition forms. A nurse confirmed the breach and moved the binder to a secure location.
The facility failed to notify the Ombudsman of resident transfers or discharges, affecting three residents who were hospitalized. Despite the requirement, there was no documentation of notification for these cases. The DON confirmed the lack of communication and acknowledged the absence of a system for notifying the Ombudsman.
The facility failed to revise care plans and conduct timely care plan meetings for residents following MDS assessments. A resident's care plan was not updated to reflect a change in wound vac status, another resident's care plan incorrectly focused on anticoagulation therapy instead of antiplatelet medication, and a third resident's care plan included interventions for a non-existent Foley catheter. Additionally, a resident reported not having a care plan meeting, and documentation confirmed a delay in scheduling it.
The facility failed to provide adequate ADL care for several residents, as evidenced by missing documentation and reports from residents about not receiving showers or grooming assistance. The DON could not provide documentation of showers being offered or completed, and residents were observed with poor hygiene and grooming.
The facility failed to maintain proper sanitation and food safety standards, with surveyors observing issues such as an overstocked freezer, incomplete temperature logs, and unlabeled food items. Wet-nesting was noted in the kitchen, and a beverage cart with expired drinks was left unattended. The DON acknowledged that procedures were not followed.
A facility failed to provide timely podiatry consultations for a resident with recurring foot infections. Despite orders for consultations, the resident did not receive timely care due to scheduling issues and an incorrect room number, which led to missed appointments. The resident had a history of atherosclerosis and diabetes, increasing the risk of infection.
The facility failed to properly inform two residents and their representatives about changes in Medicare/Medicaid coverage and potential financial liabilities. In one case, the SNF-ABN form was not sent to the resident's representative, and in another, there was no documentation of the representative's acknowledgment. The business office staff could not confirm that the necessary notifications were made.
The facility failed to notify residents and their representatives in writing about the bed hold policy during hospital transfers. This deficiency was evident for several residents, as their medical records lacked documentation of such notifications. The DON admitted that the facility did not consistently provide these notifications and acknowledged the absence of a system to ensure compliance with the policy.
A facility failed to accurately document a resident's pressure ulcers on the MDS, leading to discrepancies between the skin conditions and active diagnoses sections. The annual MDS showed an unstageable pressure ulcer not listed in diagnoses, while the quarterly MDS had conflicting entries for a stage 4 and an unstageable ulcer. These inaccuracies were confirmed by MDS Coordinators after a surveyor's review.
A facility failed to provide a resident and their representative with a summary of the baseline care plan. The resident, who lacked decision-making capacity, was readmitted after hospitalization. Despite a care plan meeting, there was no documentation that the resident or their responsible party received the care plan. The family expressed minimal communication regarding care plan changes.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. A resident with a suprapubic catheter had no care plan for catheter care, and an inappropriate incontinence care plan was in place. Another resident had conflicting care plans for urinary incontinence and a foley catheter, which were not appropriately updated. The DON acknowledged these deficiencies.
A CMA in a LTC facility administered medications without proper labeling, violating professional standards. The CMA received unlabeled medications from a nurse, preventing verification of the five rights of medication administration. The DON confirmed that CMAs should not handle narcotics, highlighting a breach in the facility's policy.
The facility failed to follow professional standards for IV antibiotic infusions for two residents. Observations revealed unlabeled and improperly capped IV tubing, contrary to facility policy. The DON confirmed the issue and indicated staff retraining was necessary.
A surveyor observed a CMA administering unlabeled medications, including a narcotic, contrary to facility policy. The CMA claimed the medications were prepared by an RN but were not labeled, leading to a failure in ensuring accurate dispensing. The DON confirmed that CMAs should not administer narcotics, highlighting a safety concern.
The facility failed to ensure timely review and action on medication irregularity reports for three residents. One resident's Hydroxyzine prescription lacked a stop date and diagnosis, continuing beyond 14 days without physician review. Another resident's Methotrexate prescription discrepancies were noted but not corrected for 27 days. A third resident's Tylenol dosage clarification was delayed until surveyor intervention. These issues highlight lapses in communication and timely physician involvement in medication management.
A facility failed to ensure a resident's medication regimen was free from unnecessary medication by not providing an adequate indication for the use of Mirtazapine, a psychotropic medication prescribed for insomnia. Despite recommendations to reevaluate the prescription, the medication order was not changed, and the rationale for its use was not documented. The Director of Nursing acknowledged that the Medication Regimen Review report was not reviewed by the provider, and it lacked the required physician's acknowledgment of irregularity or action taken.
The facility failed to secure medication and treatment carts, with multiple instances of unattended and unlocked carts observed across different units. These carts contained medications, treatment supplies, and resident information, posing a risk to resident safety. Staff acknowledged the expectation to keep carts locked when unattended.
A facility failed to maintain complete laboratory records for a resident's vancomycin dosing. A surveyor found missing lab results in the resident's medical record, despite orders for several tests. The DON confirmed the absence of results and explained the facility's process for lab draws and documentation, revealing a lapse in ensuring lab results were completed and recorded.
The facility failed to provide or obtain dental services for two residents, despite their eligibility for on-site care through Health Direct. One resident had not received dental care since admission in 2022, and another since 2023, due to staff not signing them up for the program. The deficiency was identified during an annual survey.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in documentation regarding their decision-making capacity and life-sustaining treatment preferences. For one resident, there was a conflict between the paper and electronic records about their resuscitation wishes. Two other residents had incorrect social service assessments indicating they were responsible for their own decisions, despite certifications stating otherwise.
A facility failed to document the rationale for not administering a pneumococcal vaccine to a resident. The DON admitted that vaccine documentation in PCC was delayed due to the lack of a unit secretary. The resident did not receive the vaccine, and no declination form was signed. The IP confirmed incomplete consent forms, and the resident was not registered in ImmuNet.
The facility's kitchen walk-in freezer was found in unsafe condition with ice buildup, melting water, and missing strip curtains. The freezer's fans were not running, leading to water accumulation on the floor and wet food packages. The Director of Maintenance was unaware of the defrost mode's duration and was not certified to work on the commercial freezer.
The facility failed to maintain an effective pest control program, with surveyors observing gnats and mouse droppings in the kitchen and nursing unit. Pest control reports indicated ongoing issues with mice and roaches, and a needed door sweep was not yet installed, contributing to the deficiency.
A resident's call bell was not responded to for 14 minutes despite being illuminated and audible at the nursing station. GNAs were observed attending to another resident without an active call bell, and the Unit Secretary had informed a GNA of the need for assistance. Eventually, an RN responded, but the delay highlighted a failure in timely response expectations as stated by the DON.
Fall Event Not Coded on Quarterly MDS Assessment
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment when a resident’s documented fall was not coded on the quarterly MDS. Medical record review showed that the resident experienced a fall on 1/18/26 at 13:45, sustained a hematoma, and was sent to the emergency room for evaluation. However, review of the resident’s quarterly MDS with an assessment reference date of 4/2/26 revealed that Section J (falls) did not capture this fall event. During an interview, the MDS Coordinator confirmed that the MDS had been completed by another staff member who was not present that day and acknowledged that the fall had been omitted from the assessment.
Failure to Activate EMS Promptly During CPR for Full-Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and its own CPR policy when responding to a resident’s cardiac arrest. The resident had a MOLST form indicating "Attempt CPR" (full code). On the night in question, the resident was found unresponsive with no palpable pulse, and staff initiated CPR and ventilations. The nursing supervisor documented that CPR began at approximately 1:00 AM. However, instead of immediately activating EMS, the nursing supervisor left the room to call the resident’s responsible party to confirm continuation of full code status, then called the on-call provider, who instructed to continue CPR and notify 911. EMS was not called until after these contacts were made. The EMS report documented that 911 was called at 1:16 AM, EMS arrived at 1:21 AM, and the resident was pronounced deceased at 1:23 AM. The EMS report also noted the resident was in bed in cardiac arrest, skin was cold, and rigor mortis had begun to set in, while facility staff were providing CPR with an AED that did not advise a shock. The facility’s CPR policy states that if a patient does not have a DNR order, CPR-certified staff will initiate CPR and EMS will be activated. The AHA 2025 CPR guidelines referenced in the report state that after checking responsiveness and shouting for help, the emergency response system should be activated and someone sent for an AED before starting CPR if there is no breathing or pulse. During interviews, the nursing supervisor acknowledged calling the family and provider before 911, and facility leadership confirmed that staff failed to call 911 prior to contacting the resident’s representative and on-call provider, contrary to standards of practice.
Failure to Follow Physician Medication Orders and Hold Parameters
Penalty
Summary
Facility staff failed to administer and hold medications according to physician orders for three residents. For one resident with heart failure who had been admitted in 2023, a nurse practitioner ordered an increase of Lasix from 20 mg to 40 mg daily for seven days following an emergency room visit for abnormal labs. The Medication Administration Records (MARs) for February and March 2026 showed the resident received Lasix 40 mg through 3/6/26, but staff did not resume the original Lasix 20 mg dose on 3/7/26 as ordered. The medication was not restarted until 3/8/26, resulting in a missed dose on 3/7/26, which the Administrator confirmed. For a second resident admitted in June 2022 with cerebral infarction and hypertension, physician orders for Amlodipine Besylate 10 mg daily included parameters to hold the medication if systolic blood pressure (SBP) was less than 110 or heart rate was less than 60 beats per minute. Review of MARs from December 2025 through April 2026 showed multiple instances where the medication was administered despite heart rates below 60, including readings of 50, 51, 52, 54, 55, 56, and 59 beats per minute. These doses were given by various LPNs on multiple dates, outside the ordered parameters. The resident’s care plan directed staff to assess and monitor vital signs as ordered, report abnormalities to the physician, and monitor apical heart rate, but nursing notes did not document that the medication was held or that the physician was notified when parameters were not met. For a third resident admitted in January 2026 with diastolic congestive heart failure and supraventricular tachycardia, physician orders for Metoprolol Tartrate 25 mg twice daily for hypertension included instructions to hold the medication for SBP below 110 or heart rate below 60. Review of the January and February 2026 MARs showed the medication was administered when SBP readings were below 110, including 109/68, 106/66, and 99/57. These doses were given by an LPN and an agency RN, contrary to the ordered parameters. The resident’s care plan required staff to administer medications as ordered, assess for effectiveness and side effects, and report abnormalities to the physician, but nursing notes did not show that the medication was held or that the physician was notified when blood pressure readings were below the ordered threshold. Interviews with the DON and nursing staff confirmed the concern that medications were administered outside physician-ordered parameters.
Failure to Administer Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident was not administered their prescribed morning medications as ordered on June 13, 2025. Record review and interviews confirmed that the resident did not receive multiple medications, including Furosemide, Folic Acid, Ferrous Sulfate, Docusate Sodium, Amlodipine Besylate, Amiodarone HCl, Losartan Potassium, Metformin HCl, Metoprolol Succinate, Gabapentin, and Acetaminophen. The Medication Administration Record (MAR) for that date did not show documentation of medication administration, and there was no record of vital signs being obtained. An SBAR note in the medical record also indicated that the resident was not given their morning medications. Interviews with staff revealed that nurses are expected to document medication administration immediately after giving medications and to note reasons for any missed doses. The Director of Nursing confirmed that the incident was reported and substantiated, and the facility's incident report noted that the nurse assigned to the resident had a disorganized medication cart and spent significant time searching for medications. The nurse involved did not provide a statement regarding the incident.
Resident Received Double Dose of Synthroid Due to Medication Order Error
Penalty
Summary
A deficiency occurred when a resident received double doses of Synthroid (levothyroxine) due to a failure in medication order management. The resident's endocrinologist faxed a new order to increase Synthroid to 150 mcg, which was verbally verified by the in-house NP and transcribed by the assigned nurse onto the medication administration record (MAR). However, the previous order for Synthroid 137 mcg was not discontinued, resulting in the resident receiving both the old and new doses for four consecutive days. This medication error was identified during a review of the resident's medical records and confirmed by the Director of Nursing (DON), who stated that staff are expected to double-check medication orders and discontinue previous orders when new ones are received. The error led to the resident receiving double the intended dose of Synthroid, which was also associated with an abnormal lab value as noted in the complaint.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy (PT) services as ordered for one resident. According to the resident's physician order, PT was to be provided five times per week for four weeks, totaling 20 sessions. However, documentation showed that the resident only received 15 PT sessions during this period. The Director of Rehab stated she believed the order was for 3-5 sessions per week rather than five, and attributed the missed sessions to scheduling conflicts. The Director of Nursing acknowledged ongoing issues with residents missing therapy sessions.
Staff-to-Resident Verbal and Non-Verbal Abuse
Penalty
Summary
The facility failed to maintain an environment free from staff-to-resident verbal and non-verbal abuse for two residents. In the first incident, a housekeeper used curse words and made a threatening gesture by raising a middle finger toward a resident in the resident's bedroom. The resident involved had diagnoses including congestive heart failure, pulmonary hypertension, atrial fibrillation, morbid obesity, hypertensive heart disease with heart failure, difficulty walking, muscle weakness, and adjustment disorder with anxiety. The resident was assessed by nursing and social services following the incident, and no ill effects were noted at that time. In the second incident, a general nursing assistant verbally abused another resident and used derogatory comments while providing care. The resident had cognitive communication deficits, congestive heart failure, chronic kidney disease, and was documented as cognitively impaired with a BIMS score of 6/15. The resident was dependent on staff for emotional, intellectual, physical, and social needs. During care, the nursing assistant used profane language, including telling the resident to "kiss my ass" and "fuck you," and refused to assist with breakfast requests. Multiple staff statements and interviews confirmed the use of abusive language and inappropriate conduct toward the resident. Both incidents were reported by staff and confirmed through interviews and written statements. The facility's policies prohibit all forms of abuse, including verbal and mental abuse, and require immediate reporting of suspected abuse. The actions of the housekeeper and the nursing assistant were in direct violation of these policies, resulting in the documented deficiencies.
Failure to Clarify Medication Orders and Monitor Vancomycin Levels
Penalty
Summary
The facility failed to clarify a medication discrepancy on the hospital discharge summary for a resident who was prescribed Vancomycin for bacteremia. The discharge summary contained conflicting orders for Vancomycin administration, listing both once daily and twice daily dosages. The facility did not document any clarification of these orders, leading to the administration of Vancomycin twice daily without proper verification. This discrepancy was not addressed by the nursing staff or the nurse practitioner, resulting in the resident receiving an incorrect dosage. Additionally, the facility did not appropriately monitor the Vancomycin dosing by ordering the correct laboratory tests. Random Vancomycin levels were obtained instead of the recommended trough levels, which are necessary for accurate dosing. Despite obtaining high random Vancomycin levels, no action was taken by the nurse practitioners who reviewed the results. The resident's Vancomycin levels continued to rise, reaching toxic levels, which were not addressed until the resident was transferred back to the hospital with Vancomycin toxicity and acute renal failure. The facility's process for handling laboratory results and medication orders was inadequate. The laboratory results were not consistently flagged for review, and there was a lack of communication between the facility and the pharmacy regarding the Vancomycin levels. The medical director and nurse practitioners did not ensure that the correct laboratory tests were ordered or that abnormal results were acted upon. This failure in the facility's processes led to harm to the resident, who was eventually diagnosed with acute renal failure due to Vancomycin toxicity.
Confidentiality Breach of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident medical records, as evidenced by the accessibility of a laboratory log. During an initial tour of the nursing unit, surveyors observed a black binder on the countertop at the nursing station. This binder contained a laboratory log with the names and laboratory information of seven residents. The log included documents such as resident lab test logs, lists of residents scheduled for specific labs, Clinical Laboratory Outpatient Requisition forms, and lab and diagnostic records from Point Click Care (PCC). A Registered Nurse confirmed that the binder was the resident's laboratory log and acknowledged that it should have been stored behind the nursing station, away from public access. The nurse then removed the binder from the countertop and placed it behind the nursing station.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers or discharges, as required. This deficiency was identified during a survey that reviewed the cases of five residents who were hospitalized. Specifically, the facility did not notify the Ombudsman about the hospitalizations of three residents. Resident #17 was transferred to the hospital on March 15, 2024, but there was no documentation of Ombudsman notification. The Director of Nursing (DON) confirmed the lack of communication after consulting with the Social Worker and business office. Similarly, Resident #90 was transferred to the hospital in March 2024 for treatment of sepsis, but again, there was no documentation of Ombudsman notification. The DON was unable to provide evidence of such notification. Additionally, Resident #73 was transferred to the hospital in October 2023, and while the resident's representative was informed, there was no record of Ombudsman notification. The DON acknowledged the absence of a system for notifying the Ombudsman and indicated that the responsibility would be assigned to the Guest Services Director moving forward.
Deficiencies in Care Plan Revisions and Meetings
Penalty
Summary
The facility failed to revise care plans and hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This deficiency was evident in several cases. Resident #42 had a physician order to hold a wound vac due to active bleeding, but the care plan was not updated to reflect this change. Resident #80's care plan incorrectly focused on anticoagulation therapy, despite the resident being prescribed an antiplatelet medication, Clopidogrel, and Aspirin, with no anticoagulant medication ordered. Additionally, Resident #75's care plan included interventions for a Foley catheter that the resident did not have, and there was no documentation of a resolved pressure ulcer on the care plan. Furthermore, Resident #322 reported never having a care plan meeting. The medical record review confirmed that a comprehensive care plan was not completed following the baseline care plan. The Director of Nursing acknowledged the expectation to have a care plan meeting within 7 days after completing the comprehensive assessment, but documentation of such a meeting was not found. The Social Services Director and Staff #51 confirmed the delay in scheduling the care plan meeting for Resident #322.
Deficiencies in ADL Care and Documentation
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care in accordance with the care plans for several residents. Resident #322 reported never being offered a shower, despite care plans indicating the importance of choosing between different bathing options. The shower logbook lacked documentation for the entire month of April, with only two entries dated 4/20/24 and the next dated 3/18/24. The Director of Nursing (DON) could not provide documentation that a shower was offered or completed for Resident #322, with only bed baths recorded. Resident #97 also reported never having been in the shower since admission, only being offered a pan of water for bathing. Similar to Resident #322, the shower logbook lacked documentation, and the DON could not provide evidence of showers being offered or completed. Resident #321 was observed with a film on their teeth, and the care plan indicated a need for assistance with ADLs due to recent illness and limited mobility. Again, the DON could not provide documentation of showers being offered or completed, with only bed baths recorded. Resident #41 was observed with poor grooming, wearing a food-stained gown, and having crusty eyes and leftover food on their face. The resident stated they did not receive morning grooming assistance, and the Unit Manager confirmed the failure to provide such assistance. Resident #80 was observed with a black substance under their fingernails over multiple days, and the care plan indicated dependency on staff for personal hygiene and bathing. The DON stated that nail care should be performed during showers or bed baths, but there was no documentation of refusal or care provided.
Sanitation and Food Safety Deficiencies in Kitchen and Nursing Units
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen and on nursing units, as observed during an annual survey. In the kitchen, surveyors noted several deficiencies, including a missing dish machine log, an overstocked and disorganized walk-in freezer with food items on the floor, and the presence of gnats. Additionally, there was ice and sediment on the freezer fan, ice on food items, and an open loaf of bread. The kitchen floor was littered with crumbs and stains, and there was wet-nesting of serving pans, which is against FDA guidelines. The surveyors also found a broken hand sink and trash piled up at the kitchen entrance. On the nursing units, the surveyors observed incomplete temperature logs and dirty nourishment refrigerators with spilled substances and unlabeled food items. The Director of Nursing acknowledged that the expectation was for daily temperature checks, cleanliness, and proper labeling of food items. The surveyors also noted expired and unlabeled food items in the dry storage area and wet-nesting on food preparation pans. During meal delivery, wet-nesting was observed on plate lids used to cover residents' food. A beverage cart was left unattended in the hallway with expired beverages, lacking proper temperature control. The Unit Manager and Kitchen Serving Staff confirmed that expired beverages should not have been served, and the cart should not have been left in the hallway. The Director of Nursing agreed that the correct procedures were not followed, leading to these deficiencies.
Failure to Provide Timely Podiatry Consultations
Penalty
Summary
The facility failed to ensure timely podiatry consultations for a resident with recurring foot infections. On July 28, 2022, a provider noted erythema in the resident's right first toe and recommended a podiatry consult, which was not scheduled by the facility. The resident's medical records showed a physician's order for a podiatry consult to be scheduled by August 2, 2022, but there was no evidence that this consult occurred. Subsequent medical records revealed that the resident continued to experience issues with the right great toe, including an open wound and black crust near the nail, prompting another podiatry consult order on October 7, 2022. A podiatry note from October 1, 2022, indicated the resident had generalized atherosclerosis and an ingrown toenail, which was treated. The note also highlighted the resident's increased risk of infection due to co-morbidities such as Type 2 Diabetes Mellitus and peripheral circulatory disorders. The Director of Nursing (DON) later stated that the resident was not in the facility at the time of the scheduled podiatry consults. However, documentation from the Health Drive Podiatry group indicated that the resident was unavailable due to an incorrect room number, not because the resident was absent from the facility. This discrepancy contributed to the failure to provide timely podiatry care, as the resident's location could not be verified, leading to missed consultations.
Failure to Notify Residents of Coverage Changes
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were properly informed of changes in Medicare/Medicaid coverage and potential financial liabilities for services not covered. This deficiency was identified during a review of the Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) forms for two residents. In the case of one resident, the SNF-ABN form was not sent to the resident's representative as requested, and there was no documentation of the representative's acknowledgment or refusal to sign the form. The business office staff was unable to provide a clear explanation for this oversight. For another resident, the SNF-ABN form lacked any signature or acknowledgment, and there was no evidence that the form was communicated to the resident's representative. Although an email was sent regarding the Notice of Medicare Non-Coverage (NOMNC), it did not include the SNF-ABN form. The business office manager admitted that there was no documentation to confirm that the representative was informed about the SNF-ABN form, highlighting a failure in the facility's process to ensure proper notification and acknowledgment of coverage changes.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to have an effective system in place to ensure that residents and their representatives were notified in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified during the annual survey for five residents who were hospitalized. The surveyor found no documentation of bed hold notifications in the medical records of these residents. The Director of Nursing (DON) admitted that the facility almost always did not provide these notifications and acknowledged that the process was a shared responsibility that needed improvement. Specific instances included the lack of bed hold notifications for residents who were recently hospitalized. For example, Resident #6 and Resident #43 had no bed hold notices in their records, and the DON confirmed the absence of such documentation. Similarly, Resident #17, Resident #90, and Resident #73 also lacked written notifications of the bed hold policy, despite being transferred to the hospital. The DON explained that the expectation was for nursing staff to provide the bed hold policy at the time of transfer, with the business office following up the next day. However, there was no system in place to ensure this process was completed, and the facility's policy requiring written notice to be maintained in the medical record was not followed.
Inaccurate MDS Documentation for Pressure Ulcers
Penalty
Summary
The facility failed to accurately document a resident assessment on the Minimum Data Set (MDS) for a resident, leading to discrepancies in the recorded information. The MDS is a critical tool used for assessing the health status of residents in long-term care facilities, and it is federally mandated for clinical assessments. In this case, the surveyor found that the annual MDS for the resident indicated an unstageable pressure ulcer in the skin conditions section, but this was not reflected in the active diagnoses section. Similarly, the quarterly MDS showed a stage 4 pressure ulcer in the skin conditions section, but the active diagnoses section listed both an unstageable pressure ulcer of the sacral region and a stage 4 pressure ulcer of an unspecified part of the back. The discrepancies were identified during a review of the resident's medical records and confirmed through interviews with the MDS Coordinators. The surveyor explained the inconsistencies to the coordinators, who acknowledged the inaccuracies in the documentation. The failure to accurately document the resident's condition on the MDS assessments highlights a deficiency in the facility's assessment and documentation processes, as evidenced by the inaccurate coding of the resident's pressure ulcers.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility staff failed to provide a resident and their representative with a summary of the baseline care plan, which was identified during an annual survey. The deficiency was evident for one resident who had been admitted to the facility in early January 2024 and was recently readmitted after a hospitalization. The resident's medical record indicated that two providers certified the resident lacked adequate decision-making capacity for health care decisions. Despite a care plan meeting being documented on March 25, 2024, after the resident's readmission, there was no documentation indicating that the resident or their responsible party received a copy of the baseline care plan. The resident's family, including the son who is the Power of Attorney, expressed minimal communication regarding changes to the care plan during a phone interview with the surveyor.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident #17, who had a suprapubic catheter, was hospitalized due to an infection after the catheter was changed. Upon readmission to the facility, there was no care plan addressing the care of the suprapubic catheter, and an inappropriate incontinence care plan was in place instead. The Director of Nursing acknowledged that a care plan for the suprapubic catheter should have been created and that the existing incontinence care plan was not suitable for a resident with an indwelling catheter. Similarly, Resident #103 was admitted with a history of benign prostatic hyperplasia and required assistance with personal care. Initially, a care plan was created for urinary incontinence, but after a foley catheter was placed due to urinary retention, a new care plan was added. However, the original incontinence care plan was not removed, leading to conflicting care plans. The Director of Nursing confirmed that maintaining both care plans was inappropriate and that the incontinence care plan should have been removed once the foley catheter was in place.
Failure to Adhere to Medication Administration Standards
Penalty
Summary
The facility failed to adhere to professional standards during medication administration, as observed by a surveyor. A Certified Medication Assistant (CMA), identified as Staff #37, was seen administering medications without proper labeling, which is a violation of the facility's policy. The CMA was observed taking medications from a cart, including a white pill believed to be Tramadol, without any label or direction on the medication cup. The CMA claimed to have received the medication from a Registered Nurse, Staff #2, who had not labeled the medications due to a malfunctioning marker. This lack of labeling prevented the CMA from verifying the five rights of medication administration, which include the right patient, drug, route, time, and dose. Further observations revealed that the CMA was given three unlabeled medications by Staff #2 to administer to different residents. The Director of Nursing (DON) confirmed that CMAs are not permitted to administer narcotic medications and acknowledged the safety concern posed by the unlabeled medications. The facility's policy mandates that medications should not be administered if the label is missing or illegible, and controlled substances should only be accessible to licensed nursing staff. The surveyor's findings highlighted a breach in the facility's medication administration policy, specifically regarding the handling and labeling of medications.
Failure to Properly Label and Cap IV Tubing
Penalty
Summary
The facility failed to adhere to professional standards of practice during the administration of intermittent intravenous (IV) antibiotic infusions for two residents. During the recertification survey, it was observed that the IV tubing for Resident #43 was not labeled with the date and was improperly inserted into an upper tubing port. The Director of Nursing (DON) confirmed that the facility's procedure required the IV tubing to be labeled, dated, and capped when not in use. The DON acknowledged the issue and indicated that staff would be retrained in the proper procedures. Similarly, for Resident #376, the surveyor noted that the IV tubing was not labeled or capped, and the end was connected to an upper port. RN #30, responsible for the resident's care, confirmed the tubing was not labeled or capped and stated that she would dispose of unlabeled tubing and replace it with new tubing. The facility's policy on the administration of intermittent infusions requires that administration sets used for more than one dose in a 24-hour period be changed every 24 hours, and that medication/solution containers and administration sets be labeled with the date, time, and nurse's initials, with a new sterile end cap placed on the end of the administration set when infusion is completed.
Medication Administration Deficiency Due to Unlabeled Medications
Penalty
Summary
The facility failed to administer medication according to procedures that ensure accurate dispensing, as observed by a surveyor. A Certified Medication Assistant (CMA) was seen administering medications without proper labeling, which is against the facility's policy. The CMA was observed taking medications from a cart, including a white pill that was not labeled, and claimed it was Tramadol, given by a Registered Nurse (RN) earlier. The CMA administered these medications to a resident without verifying the medication's identity due to the lack of labeling. Additionally, the CMA was found with other unlabeled medication cups, which she claimed were prepared by the RN, but she was unsure why they were not labeled that day. The Director of Nursing (DON) confirmed that CMAs are not permitted to administer narcotic medications, and the unlabeled medications posed a safety concern. The surveyor's review of the facility's policy indicated that medications should not be administered if the label is missing or illegible, and controlled substances should only be accessible to licensed nursing staff. The surveyor also confirmed that one of the unlabeled medications was Oxycontin, a narcotic pain medication, which was not supposed to be administered by the CMA. The resident involved was assessed and found to be at her baseline with no concerns regarding her morning medications.
Failure to Address Medication Irregularities in a Timely Manner
Penalty
Summary
The facility failed to ensure that medication irregularity reports were reviewed by the primary care physician and that recommendations were addressed in a timely manner for three residents. For Resident #103, a Medication Regimen Review (MRR) conducted on April 1, 2024, identified an irregularity with the prescription of Hydroxyzine, which lacked a stop date and a specific diagnosis. Despite the irregularity being noted, the report was not reviewed by the provider, and no action was taken to address the issue, resulting in the medication order continuing beyond the recommended 14 days. For Resident #90, the MRR identified discrepancies in the Methotrexate prescription, which was written differently from the hospital transfer summary. The report recommended a dose adjustment and clarification of the medication's indication. Although a provider noted the issue on January 5, 2024, the recommendation was not implemented until 27 days later, with no documented rationale for the delay or for not following the initial pharmacy recommendations. Resident #42's MRR from March 20, 2024, included a recommendation to clarify the dosage of Tylenol Extra Strength tablets. However, the facility failed to notify the physician of this recommendation until prompted by the surveyor's inquiry. This oversight was confirmed by the Director of Nursing, who acknowledged that the physician had not been informed of the pharmacist's recommendation until after the surveyor's investigation.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by not providing an adequate indication for the use of a psychotropic medication. The resident in question had a medical history that included cerebral infarction, abnormal gait, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The surveyor found that Mirtazapine, a psychotropic medication, was prescribed for insomnia, which is not an approved indication for its use. This was noted during a review of the resident's Medication Regimen Review (MRR) and Medication Administration Record (MAR). The Director of Nursing (DON) acknowledged that the MRR report, which recommended reevaluation of the Mirtazapine prescription, was not reviewed by the provider. The report lacked the required physician's acknowledgment of irregularity or any action taken to address it. Despite the recommendation to reevaluate or provide clinical rationale for the use of Mirtazapine, the medication order was not changed, and the rationale for its administration was not documented. The medication continued to be administered until the resident was discharged.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain a secure system for medication and treatment carts, as observed during random tours. On the 300-nursing unit, a treatment cart was found unattended and unlocked, containing scissors, ointments, creams labeled with resident names, dressings, and bandages. The assigned LPN was at the other end of the hallway, and upon request, returned to the cart to lock it. On the 400-nursing unit, a medication cart was also found unattended and unlocked, with medications labeled with resident names and room numbers, and a narcotic book with resident details. An insulin pen meant to be refrigerated was found in the cart, and the responsible LPN acknowledged the cart should be locked when unattended. On the 200 Unit, another medication cart was observed unattended and unlocked, with multiple bottles of medications and punch cards with resident doses. The responsible RN admitted to forgetting to lock the cart despite recent training on medication storage. The Director of Nursing was informed of the unlocked cart, acknowledging the concern. These observations indicate a pattern of unsecured medication and treatment carts across different units, posing a risk to resident safety.
Failure to Maintain Complete Laboratory Records
Penalty
Summary
The facility failed to maintain complete laboratory records in the medical record of a resident, specifically for vancomycin dosing. On a specified date, a surveyor reviewed the medical record of a resident and found that an order for a lab blood draw was placed by the Medical Director. The order included several tests, such as a complete blood count and vancomycin trough, to be conducted on a specific date. An additional lab order was written for further tests to be conducted weekly. However, upon review, the surveyor found that the lab results from the initial order were missing from the resident's medical record. During an interview, the Director of Nursing (DON) confirmed that the results from one of the lab draws were not in the resident's medical record and that the labs from the initial order appeared not to have been completed. The DON explained the facility's process for obtaining lab draws and the expected procedure for recording lab results. Despite other residents having their labs drawn on the same day, the resident in question did not have any lab results recorded, indicating a failure in the facility's process for ensuring lab results are completed and documented in the medical record.
Failure to Provide Dental Services
Penalty
Summary
The facility staff failed to promptly provide or obtain dental services for two residents, leading to a deficiency identified during an annual survey. Resident #74, who was admitted with diagnoses including cardiac arrhythmia, dementia, and anemia, had not received any dental visits since admission in June 2022. Despite being eligible for dental care through Health Direct since February 2023, the staff had not signed the resident up for these services. The Unit Manager confirmed the lack of dental visits and stated that a referral had only recently been completed, with the scheduling of a visit still pending. Similarly, Resident #88, admitted with conditions such as heel decubiti, Parkinson's, dementia, and chronic heart failure, had not received any dental visits since admission in September 2023. Although the resident was eligible for Health Direct services since November 2023, the staff failed to activate the resident for the program. The resident's family had inquired about the overdue dental visit, and the Unit Manager acknowledged the oversight, having only made a dental referral recently. The Director of Nursing and the Administrator confirmed the partnership with Health Direct but admitted that the services were not fully utilized, resulting in the deficiency.
Inaccurate Medical Record Documentation for Residents
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards, as evidenced by incomplete and inaccurate documentation for three residents. For Resident #322, discrepancies were found between the paper medical chart and the electronic medical record regarding the resident's wishes for life-sustaining treatments. The paper chart contained a MOLST form indicating the resident wished for cardiopulmonary resuscitation, while a progress note in the electronic record stated a new MOLST form was completed, reflecting the resident's desire to be a full code. However, the updated MOLST form was not provided to the surveyor. For Resident #103, there was a contradiction between the social service assessment and the certifications by two physicians regarding the resident's decision-making capacity. The social service assessment incorrectly indicated that the resident was responsible for their own decisions, despite certifications stating the resident lacked decision-making capacity. Similarly, for Resident #4, the social service assessment inaccurately marked the resident as responsible for their own decisions, although certifications confirmed the resident lacked decision-making capacity. These errors in documentation highlight the facility's failure to ensure accurate and complete medical records.
Failure to Document Pneumococcal Vaccination Rationale
Penalty
Summary
The facility failed to document the rationale for the non-administration of the pneumococcal vaccination for one resident during an annual survey. The Director of Nursing (DON) acknowledged that the documentation of vaccines in the Point Click Care (PCC) system was not up to date, particularly in the 200 Hall, due to the absence of a unit secretary. The process outlined by the DON indicated that the unit secretary is responsible for inputting vaccine information into PCC after administration, while floor nurses assess and administer vaccines upon admission when available from the pharmacy. During the survey, it was discovered that the resident had not been administered the pneumococcal vaccine, and no declination form was signed. The Infection Preventionist (IP) confirmed that the consent forms were incomplete and still on the resident's chart. The facility checked the ImmuNet system and found that the resident was not registered. The deficiency was identified as a failure to follow the process of obtaining consents on admission and ensuring the administration of the vaccine when available.
Unsafe Conditions in Kitchen Walk-In Freezer
Penalty
Summary
The facility failed to maintain the kitchen walk-in freezer in a safe operating condition. During an initial tour, it was observed that the freezer was filled with a cloud-like mist, making visibility difficult. There were small mounds of ice covering the ceiling, and ice clumps and icicles were present on the two circular fans of the main unit. Ice was also found on boxes of food, shelving, and food packages. Additionally, the strip curtains were missing from both the freezer and refrigerator. Upon revisiting the freezer, it was noted that the fans were not running, the ice on the fans was melting, and water was accumulating on the floor. The ice buildup on the ceiling had melted, resulting in wet boxes and food on the shelves. Water was also visible inside the light fixture attached to the ceiling. The Director of Maintenance stated that the freezer was in defrost mode but was unaware of the duration or frequency of this mode. It was also discovered that the Director of Maintenance was not certified to work on the commercial freezer.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of rodents and insects in various areas. During an initial tour of the kitchen, surveyors observed gnats flying around the bread cart and at the entrance of the kitchen. Further observations in the Nursing Unit 300 revealed gnats and mouse traps in a resident's room. A follow-up tour of the kitchen uncovered a significant amount of mouse droppings on the floor in the dry storage room, as well as an opening at the bottom of the exit doors in the service area, which could facilitate pest entry. The review of pest control reports from January to April 2024 indicated ongoing pest issues, including mice activity in various areas and treatment for roaches in the kitchen. The reports noted the need for a door sweep on the exit door, which had been communicated to maintenance. Despite these observations and reports, the facility had not effectively addressed the pest control issues, leading to the continued presence of pests in the facility.
Failure to Respond to Call Bell in a Timely Manner
Penalty
Summary
The facility failed to ensure timely response to call bells, as observed in the case of Resident #80. On the morning of 4/18/24, Resident #80 reported that their call bell was not functioning properly, although maintenance had worked on it. A surveyor confirmed the call bell was illuminated after pressing it, yet it remained unanswered for 14 minutes. During this time, Geriatric Nursing Assistants (GNAs) #13 and #14 were observed attending to another resident who did not have an active call bell. The Unit Secretary acknowledged hearing the call bell alarm and informed GNA #13, who did not respond. Eventually, Registered Nurse (RN) #2 responded to the call bell, turning it off. The Director of Nursing stated that staff are expected to respond to call bells promptly, indicating a lapse in protocol adherence.
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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