Fairfield Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crownsville, Maryland.
- Location
- 1454 Fairfield Loop Road, Crownsville, Maryland 21032
- CMS Provider Number
- 215236
- Inspections on file
- 15
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Fairfield Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was started on Seroquel 25 mg BID for agitation and mood stabilization without documented consent from the resident’s representative. Review of the medical record and MARs showed the antipsychotic was administered over multiple weeks, including a restart after a brief hold, with no evidence of obtained consent. In interviews, the prescribing physician and the DON confirmed that staff did not secure representative consent for this change in treatment.
Staff failed to maintain a clean, sanitary, and orderly room for a resident, resulting in persistent fruit flies, dirty surfaces, and unresolved maintenance issues. A complaint about fruit flies led to observations of multiple food trays with leftover food left in the room, visibly dirty bedside tables and dresser drawers, debris on the floor, and peanut butter jars with residue on the outside. On a subsequent visit, numerous fruit flies were counted in the bathroom and on walls and the sink, large cobwebs were present around closet doors, and the room still had dirty drawers and uncontained peanut butter jars. Additional issues included a constantly running toilet, an unused open-ended pipe near the toilet, cracked drywall around the sink, and old drill holes under the television, all confirmed by the DON.
Staff failed to follow physician orders for two residents, resulting in missed wound care and improper preoperative management. One resident with a non-pressure sacral wound did not receive the ordered daily silver sulfadiazine and calcium alginate dressings for several weeks after the wound physician initiated and reaffirmed these orders. Another resident scheduled for an outpatient vascular procedure received food and fluids despite NPO instructions, did not have Eliquis stopped as ordered, and did not receive the permitted morning doses of Aspirin, Metoprolol, Vimpat, and Gabapentin, leading to rescheduling of the procedure. The DON confirmed these failures to follow the consultant and vascular physicians’ orders.
The facility did not follow professional standards for medication administration, including giving a resident a medication that was supposed to be held, leaving medications and an insulin pen in a resident's room, and repeatedly documenting medication administration late for several residents. Nursing staff confirmed that high workload and lack of support staff contributed to delays in both administering and documenting medications.
Multiple residents requiring substantial or total assistance with bathing did not receive showers as ordered, with documentation showing extended periods between showers and no records of refusals. Staff and resident interviews attributed missed showers to staffing shortages and high resident-to-GNA ratios, resulting in inadequate hygiene care, including infrequent changing and turning. Facility leadership confirmed the expectation for twice-weekly showers and proper documentation, but these standards were not met.
A complaint investigation revealed that the call bell system on one unit was not functioning properly, as call lights illuminated but no audible alert was heard in the hallway or at the nurse's station. A resident was observed repeatedly pressing the call bell without response, and staff confirmed they could not hear the alerts. The issue was traced to the speaker system being turned off, and leadership was unaware that this could occur.
Surveyors identified unsafe and unsanitary conditions in two outdoor areas, including dilapidated planter boxes, broken and uneven concrete, scattered rocks, a moldy sheet, loose boards, a large hose on a picnic table, and deteriorating bird houses. Both the Maintenance Director and the NHA confirmed the poor condition of these areas.
A resident's call light was found on the floor and out of reach, contrary to the care plan directive to keep it accessible at all times. The resident relied on a hand bell or yelling for assistance, and staff did not respond to the hand bell. When the call bell was finally activated, a GNA responded after several minutes.
A resident with dysphagia experienced a significant weight loss, dropping from 213 to 191 pounds between two MDS assessments. Despite this, staff incorrectly coded the MDS to indicate no substantial weight loss, a mistake later confirmed by the MDS Coordinator.
A resident returned to the facility after a six-week hospital stay and underwent a comprehensive MDS assessment, but the facility did not hold a required care plan meeting to discuss the resident's treatment and prognosis. This oversight was confirmed by the Social Work Director during a complaint survey.
Facility staff failed to provide prescribed wound care for two residents, including one with a venous leg wound and another with a diabetic toe ulcer. In both cases, nursing staff did not follow updated physician orders, resulting in missed or improperly documented treatments, as confirmed by facility leadership.
A resident admitted with a sacral pressure ulcer did not receive the wound care team's prescribed treatment plan, as nursing staff failed to communicate and enter the correct orders into the system. Instead, a different wound care regimen was documented and provided, resulting in a deficiency in pressure ulcer care.
A resident with dysphagia experienced significant unplanned weight loss over several months due to staff failing to promptly follow the dietitian's recommendations for nutritional supplements and appetite stimulants, and not notifying the provider of continued weight loss. Despite monthly assessments, no further interventions were implemented, and the provider remained unaware of the ongoing decline.
A resident did not receive required face-to-face visits from a physician, PA, or NP within the mandated 60-day interval, with a gap of 76 days between documented visits. Staff confirmed the absence of provider notes during this period.
A resident with multiple complex medical conditions did not receive prescribed Tramadol for several scheduled doses due to the medication not being available. Interviews with the ADON, RN unit manager, and an LPN indicated that the pharmacy could have delivered the medication within hours if contacted, but there was no documentation that the physician was notified or that appropriate steps were taken to obtain the medication.
A resident with multiple diagnoses, including hypertension, was prescribed three antihypertensive medications with physician-ordered parameters to hold doses if blood pressure was below a certain threshold. Blood pressure was only consistently documented for the morning dose, with no documentation for the afternoon and evening doses of one medication. The MAR lacked designated spaces for recording required blood pressure readings, and this omission was confirmed by nursing leadership during the survey.
Surveyors found that staff failed to keep medication carts locked and unattended, left pre-poured medications unlabeled, and did not date or properly refrigerate opened medications such as inhalers and insulin pens. These actions were not in accordance with facility policy or manufacturer instructions.
A resident with dysphagia and recent significant weight loss reported issues with ill-fitting dentures. Although the concern was communicated to nursing management and a dental hygienist documented the need for a dental evaluation, the resident was not seen by a dentist as scheduled and did not receive the required follow-up dental services.
Two residents with orders for mechanical soft, ground meat diets due to swallowing and aspiration risks were served meat in cubed and chunked forms rather than ground, as required by their dietary orders. Staff and dietary leadership confirmed the meals were not prepared according to the prescribed consistency.
A resident with multiple chronic conditions and cognitive impairment had significant gaps in meal consumption documentation by GNAs, with numerous days missing records for breakfast, lunch, and/or dinner. This incomplete documentation prevented validation of the resident's food intake, and facility leadership confirmed the deficiency.
A resident with advanced cancer and a history of unsuccessful radiation treatment requested hospice care, with both the resident and family expressing this wish. Although the PCP was notified and directed staff to contact hospice, there was no documentation of a hospice order or initiation of services during the resident's stay. Staff interviews revealed inconsistent processes for handling hospice requests, and hospice care was only arranged after the resident was discharged home.
Required nurse staffing data, including staff names and actual hours worked, was not posted at the start of each shift in the facility's lobby or nursing units. Observations over two days found outdated or incomplete information, and interviews with the ADON and HR Director confirmed that postings were not maintained during the scheduler's absence.
The facility failed to conduct and document timely care plan meetings for several residents, as evidenced by missing documentation and staff interviews. A resident had a care plan conference upon admission, but no subsequent meetings were documented. Another resident reported not having care plan meetings, and their records lacked documentation despite multiple MDS assessments. A third resident's care plan meeting was canceled and not rescheduled promptly, with no documentation found. These deficiencies indicate a systemic issue in the facility's care planning process.
The facility failed to maintain a safe environment, as two residents were observed with safety hazards in their rooms, including a high bed position and debris on the floor. Additionally, a medication cart was found unlocked, and multiple building doors were unsecured, allowing surveyors to enter without alarms or staff presence. The Administrator acknowledged the broken locks but had not implemented alternative security measures.
A surveyor found that the facility failed to store food according to professional standards, with numerous opened and unlabeled food items in the kitchen's storage areas. The Certified Dietary Manager was unaware of the facility's food safety policy, and despite being informed, the facility did not remove or discard the identified items, posing a potential risk to residents.
The facility failed to ensure a functional call light system for residents, affecting their ability to summon assistance. Multiple residents reported non-functional call lights, with no alternative devices provided. Maintenance logs lacked documentation for repair requests, and staff interviews confirmed a lack of awareness and implementation of protocols for alternative communication methods.
A resident reported not receiving showers for two years, only bed baths, despite preferring showers. The DON and ADON stated the resident was informed to request showers and believed the resident refused them, but no refusals were documented in the chart. The DON acknowledged the need for documentation of refusals.
The facility failed to ensure residents were offered the opportunity to complete Advance Directives upon admission, affecting three residents. The Social Work Director acknowledged that documentation might have been missed due to staffing changes, contributing to the deficiency.
A staff member failed to keep a resident's medical information private by leaving a medication packet with the resident's name and medication list on top of a locked medication cart. This breach of confidentiality was observed during a medication administration task.
The facility failed to provide written notification to two residents or their representatives regarding hospital transfers, as required by policy. One resident was transferred due to a dislodged Foley catheter with bleeding, and another was transferred twice for altered mental status and hypoxia. The facility's records lacked documentation of written notifications, and the Social Worker confirmed that the required notices were not provided.
Facility staff did not develop baseline care plans for a resident within 48 hours of admission, as required. Despite having care plan conferences on later dates, the initial baseline care plan was missing from the clinical record. The DON and ADON were informed of this deficiency but did not provide an explanation or present the missing care plan to the surveyor.
The facility failed to provide a resident-centered activities program for three residents, impacting their mental and psychosocial well-being. One resident was unclear about being encouraged to leave their room and had limited engagement with activities. Another resident's family reported a lack of activities, with the last assessment dated months prior. A third resident's preferences were not assessed in recent years, and activity documentation was insufficient. The Activities Director admitted to documentation backlogs and inconsistent engagement efforts.
Facility staff failed to reposition a resident to maintain or improve their range of motion and mobility. The resident was observed lying on their back in bed on multiple occasions over several days. The DON and ADON could not explain the resident's positioning and stated they would investigate.
Two residents reported issues with the dietary provisions, including consistently cold food, limited entree choices, and lack of variety in breakfast options. One resident kept personal cereal due to hunger concerns. A cook confirmed a standard breakfast menu with limited alternatives and acknowledged food supply issues.
The facility failed to protect resident information and maintain accurate medical records. A resident's personal information was found in another's record, and two conflicting MOLST forms were present in a resident's file, leading to potential confusion about their code status.
During a survey, facility staff were observed failing to follow infection control practices. A certified medication aide did not sanitize hands or wear gloves while administering medications. A nurse ignored a posted instruction to use hand sanitizer before entering a room. Additionally, a resident's catheter bag was repeatedly found on the floor, and two nurses did not address this issue.
Failure to Obtain Representative Consent for Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain consent from a resident’s representative before initiating an antipsychotic medication. The resident was admitted in October 2025 with dementia with psychotic disturbance and was assessed on 10/29/25 with a BIMS score of 6/15, indicating severe cognitive impairment. On 12/23/25, a physician (Staff #16) ordered Seroquel 25 mg twice daily, and on 12/26/25 documented that the resident was agitated, not tolerating nursing or therapy care, and that a short course of Seroquel would be started for mood stabilization. Review of the resident’s paper and electronic medical record showed no documentation that consent was obtained from the resident’s representative for the administration of Seroquel. Medication Administration Records showed that the resident began receiving Seroquel on 12/23/25 at 9:00 PM and continued to receive it twice daily through 1/27/26, when the medication was placed on hold for seven days. The February 2026 MAR showed that Seroquel 25 mg was restarted on 2/4/26 at 9:00 AM and continued until 2/6/26 at 9:00 AM. During interviews, Staff #16 confirmed that facility staff failed to obtain consent for the administration of Seroquel, and the Director of Nursing confirmed that staff failed to obtain consent from the resident’s representative for this change in treatment.
Failure to Maintain a Clean, Sanitary, and Well-Maintained Resident Room
Penalty
Summary
Facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for one resident. A complaint from January 2026 alleged a fruit fly infestation in this resident’s room. On 3/17/26, a surveyor observed several fruit flies in the room, along with two food trays left behind the resident’s door: one from the previous day’s dinner with leftover pasta, carrots, milk, and ice cream containers, and another from that morning’s breakfast with food crumbs. The bedside table in front of the resident was visibly dirty, dresser drawers were visibly dirty, debris was present on the floor by the window, and two peanut butter jars on the shelves had peanut butter on the outside of the jars. The resident’s toilet was noted to be constantly running. When asked, the resident agreed to have housekeeping clean the room, remove the food trays, and place the peanut butter jars in a sealed container. The DON later accompanied the surveyor and confirmed these observations, including seeing a fruit fly in the room. On 3/18/26, the surveyor returned and counted 15 fruit flies in the resident’s bathroom, 2 fruit flies on the wall where the food trays had been observed the previous day, and 1 fruit fly on the sink. Large cobwebs were observed around both closet doors, dresser drawers remained dirty, and the peanut butter jars still had peanut butter on the outside and were not in a sealed container. Additional maintenance issues were noted, including an open-ended pipe next to the toilet protruding from the wall that did not appear to be in use, dry wall around the sink with large cracks, and old drill holes in the wall under the television. The resident again stated willingness to have a scheduled cleaning time. The DON again accompanied the surveyor and confirmed these observations.
Failure to Follow Wound Care and Preoperative Physician Orders
Penalty
Summary
Facility staff failed to follow consultant physician orders for two residents, resulting in missed and incorrect treatments. For one resident who returned from the hospital and was seen by a wound physician, the wound doctor identified a non-pressure sacral wound and ordered daily application of silver sulfadiazine and calcium alginate dressings starting on 1/28/26, with reaffirmed orders on 2/3/26 and 2/10/26. Review of the resident’s January 2026 medication and treatment records showed that these ordered sacral wound treatments were not initiated until 2/18/26, resulting in a 21-day delay in implementing the prescribed wound care. The DON confirmed that staff did not provide the ordered sacral wound treatments during this period. For another resident admitted from the hospital and scheduled for an outpatient vascular procedure on 12/12/25, the vascular physician’s office sent preoperative instructions specifying that the resident should have nothing by mouth after midnight before the procedure, that Eliquis should be stopped two days prior, and that Aspirin, Metoprolol, Vimpat, and Gabapentin could be taken the morning of surgery with a small sip of water. The medical record showed the resident was given food and fluids after midnight on the day of the scheduled procedure. The December 2025 MAR further showed staff did not stop Eliquis two days prior and did not administer the allowed morning medications (Aspirin, Metoprolol, Vimpat, and Gabapentin) on the day of the procedure. The resident’s outpatient vascular procedure was subsequently rescheduled, and the DON confirmed staff failed to follow the preoperative instructions.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for multiple residents, as evidenced by direct observations, interviews, and medical record reviews. One resident was given Metformin despite a physician's order to hold the medication for two days following a procedure. The resident reported that the nurse left the medication in the room without ensuring it was taken and also left an insulin pen labeled for another resident. The same nurse was previously documented for attempting to administer Metformin when it was not scheduled and for administering another resident's insulin to the wrong individual. A review of medication administration records (MARs) for several residents revealed a consistent pattern of late documentation and possible late administration of medications. Medications such as Gabapentin, Hydralazine, Acetaminophen, Aspirin, Eliquis, Phenytoin, Amlodipine, chlorhexidine gluconate, and Humalog insulin were frequently signed off hours after the scheduled administration times. In many cases, it was unclear whether the medications were actually given late or if the documentation was completed later in the shift, raising concerns about the accuracy and timeliness of medication administration and record-keeping. Interviews with nursing staff confirmed that medications were sometimes administered or documented outside the required one-hour window due to workload and staffing issues. Staff acknowledged that when a medicine aide was unavailable, nurses were responsible for a higher number of residents, which led to delays in both medication administration and documentation. Facility leadership agreed that these practices were a concern and did not meet professional standards of quality.
Failure to Provide Required Showers and Hygiene Care Due to Staffing Shortages
Penalty
Summary
Facility staff failed to provide showers twice weekly to multiple residents who required assistance with activities of daily living, as evidenced by medical record reviews, observations, and interviews. Several residents with significant medical conditions, such as systemic lupus erythematosus, chronic pain, heart failure, hemiplegia, and cognitive deficits, were documented as needing substantial or total staff assistance for bathing and showering. Despite physician orders specifying shower days, records showed that these residents often received only bed baths or went extended periods without showers, with no documentation of refusals. Interviews with staff and residents revealed that the lack of showers was not due to resident refusals but rather staffing shortages and time constraints. Staff reported high resident-to-GNA ratios, sometimes as high as 27 residents per two GNAs, which limited their ability to provide showers and even basic hygiene care such as changing and turning residents. Residents and their representatives confirmed that showers were missed and that refusals were not the cause, with some residents stating they were only changed once per shift and not turned as frequently as required. Observations further supported these findings, with one resident noted to have a strong odor of feces and visibly dirty hair, and documentation confirming missed showers over multiple weeks. Facility leadership acknowledged the expectation for twice-weekly showers and the need to document refusals but admitted that this was not being done. The deficiency was identified for five residents during the complaint survey, with consistent evidence of missed showers, lack of documentation, and inadequate hygiene care.
Failure to Maintain Audible Call Bell System in Resident Rooms
Penalty
Summary
The facility failed to maintain a working call bell system on one of its nursing units, as evidenced by multiple observations and interviews during a complaint survey. Family members reported that the call bell in a specific room did not illuminate in the hallway, and staff informed them that the call bell was either not working at the desk or the volume was turned down. Upon investigation, the surveyor found that while the call light illuminated over the doorway when activated, there was no audible sound in the hallway. This issue was confirmed by staff present at the time, who also could not hear the call bell. Additional rooms were tested, and in each case, the call lights illuminated but no audible alert was heard. A resident was observed repeatedly pressing the call bell button without any response, and resorted to using a hand bell, which also could not be heard at the nurse's station. Staff at the nurse's station confirmed they did not hear any call bells ringing. The Director of Maintenance later discovered that the speaker system was turned off, as indicated by a muted speaker icon on the computer screen. The Assistant Director of Nursing and the RN unit manager were unaware that staff could turn off the call bell sound and needed to investigate the cause. The deficiency was communicated to the Director of Nursing and the Regional Representative during the exit conference.
Unsafe and Unsanitary Outdoor Areas Identified During Complaint Survey
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in two outdoor areas accessible to residents, visitors, and staff. During a complaint survey, observations revealed that the courtyard where residents were permitted to smoke contained dilapidated wooden flower bed planter boxes that were falling apart, as well as multiple areas of broken, crumbled, and chipped concrete, creating uneven walking surfaces. Additionally, rocks of various sizes were scattered throughout the area. The Maintenance Director confirmed that the flower beds had not been used in 6 to 7 years and stated that repairs to the concrete would require a contractor. Further inspection of another courtyard adjacent to the dining room, which was also accessible to residents and visitors, revealed a wet, moldy sheet bunched up on a window radiator, two boards propped against a brick wall, a large hose placed on top of a picnic table, and dilapidated bird houses barely hanging on a post. The Nursing Home Administrator acknowledged and confirmed the poor condition and unattractiveness of these areas during the survey.
Failure to Ensure Call Light Accessibility per Care Plan
Penalty
Summary
Surveyors determined that the facility failed to ensure a resident's call light was within reach as required by the individualized care plan. During observation, the resident was found lying in bed with a hand bell on the tray table and the call bell cord on the floor, out of reach. The resident reported using the hand bell or yelling for assistance because staff did not respond to the bell. When the surveyor tested the hand bell, there was no response, but when the call bell was activated, a geriatric nursing assistant responded after several minutes. The care plan for the resident specifically documented the intervention to keep the call light within reach at all times, which was not followed.
Inaccurate Coding of MDS Assessment for Resident Weight Loss
Penalty
Summary
Facility staff failed to accurately code the Minimum Data Set (MDS) assessment for a resident with a diagnosis of dysphagia. Medical record review showed that the resident's weight decreased from 213 pounds to 191 pounds between two MDS assessments, representing a 22-pound or 10.3% weight loss over the period. Despite this significant weight loss, staff coded the MDS Section K0300 as 'No' for weight loss, indicating that the resident had not experienced a loss of 5% or more in one month or 10% or more in six months. The MDS Coordinator confirmed during interview that this coding was inaccurate and should have reflected the weight loss.
Failure to Hold Care Plan Meeting After Resident's Return from Hospitalization
Penalty
Summary
The facility failed to hold a care plan meeting following the completion of a comprehensive MDS assessment for a resident who had recently returned from a six-week hospital stay. After the resident experienced a change in condition and was transferred to an acute care hospital, they returned to the facility, and an MDS assessment was completed. However, there was no documentation in the medical record indicating that a care plan meeting was held after this assessment. During an interview, the Social Work Director confirmed that a care plan meeting should have been conducted in the month following the resident's return but acknowledged that it was not held. The absence of this meeting was attributed to an oversight, as it "fell through the cracks." This deficiency was identified during a complaint survey and was substantiated by both medical record review and staff interview.
Failure to Provide Physician-Ordered Wound Care Treatments
Penalty
Summary
Facility staff failed to provide wound care treatment as prescribed by physicians for two residents reviewed during a complaint survey. For one resident with a history of systemic lupus erythematosus and venous thrombosis, the medical record showed a venous wound on the left calf with several changes in the treatment plan over time. Despite updated physician orders, the treatment administration record (TAR) indicated that wound care was only provided up to a certain date, with no documentation or explanation for the gap in care before the resident was sent to the hospital. Facility leadership confirmed that the treatment change was not carried out by the nursing staff. For another resident with polyneuropathies, chronic pain, and type 2 diabetes mellitus, the medical record documented a diabetic wound on the right first toe. The TAR showed two overlapping physician orders for wound care, with nurses signing off daily for both treatments. However, the Assistant Director of Nursing confirmed that the treatments were not performed correctly, as the first order was not discontinued when the second was entered, making it unclear whether both treatments were actually provided or if the documentation was inaccurate.
Failure to Follow Wound Care Orders for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident admitted with a sacral ulcer. Upon admission, the resident had a sacral ulcer that was unstageable with slough, and later identified as a Stage 4 pressure wound. The wound care team established a specific treatment plan, including the application of Leptospermum honey, alginate calcium, and a secondary gauze dressing, all to be applied once daily for 30 days. However, the Treatment Administration Record (TAR) for February and March documented a different treatment regimen, involving cleansing with normal saline solution (NSS) and application of mepilex with a cover dressing, which was signed off by nursing staff over several weeks. An interview with the Assistant Director of Nursing (ADON) and the RN unit manager confirmed that the nurses failed to relay the wound care team's orders and did not enter them into the computer system. As a result, the prescribed wound care treatments were not implemented as ordered by the wound care team, leading to a deficiency in the facility's pressure ulcer care for the resident.
Failure to Timely Implement Dietitian Recommendations and Notify Provider of Ongoing Weight Loss
Penalty
Summary
Facility staff failed to follow the dietitian's recommendations in a timely manner and did not notify the resident's physician or nurse practitioner of ongoing weight loss. The resident, who had a diagnosis of dysphagia, experienced significant weight loss over several months. The dietitian initially recommended a nutritional supplement (Med Pass 2.0) twice daily after noting weight loss, and later increased the recommendation to three times daily, also suggesting consideration of an appetite stimulant. However, there was a delay of 20 days before the appetite stimulant was ordered, and no further interventions were implemented despite continued weight loss. Throughout this period, the resident's weight continued to decline, with documentation showing a total loss of 35 pounds over approximately one year. Despite monthly assessments by the dietitian, there was no evidence that the resident's physician or nurse practitioner was notified of the ongoing weight loss after the initial intervention. Interviews confirmed that the nurse practitioner was unaware of the continued weight loss and that facility staff did not timely communicate these changes or implement recommended interventions.
Failure to Ensure Timely Provider Visits
Penalty
Summary
Facility staff failed to ensure that a resident received required face-to-face visits from a physician, physician assistant, or nurse practitioner at least every 60 days. Medical record review showed that the resident, who was admitted in 2015 and later transferred to the hospital, was not seen by any of these providers for a period of 76 days between late April and early July 2025. Staff interviews confirmed the absence of documented visits during this interval, indicating that the required provider visits did not occur as mandated.
Failure to Timely Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to timely provide prescribed medication to meet the needs of a resident admitted for rehabilitation following an acute care stay. The resident had multiple diagnoses, including paralytic syndrome after cerebral infarction, pain, hypertension, dementia, restless leg syndrome, neuralgia/neuritis, and a sacral ulcer. A physician's order for Tramadol 50 mg to be administered four times daily was written, but the medication was not available and not administered at multiple scheduled times over several days, as documented in the Medication Administration Record (MAR). Interviews with the Assistant Director of Nursing (ADON), a Registered Nurse unit manager, and an LPN revealed that there was no valid reason for the delay in obtaining the medication, as the pharmacy could have delivered it within four hours if contacted. The LPN stated that the process required the doctor to call the pharmacy, but also mentioned that the resident's spouse did not want the medication administered due to concerns about drowsiness. There was no documentation that the physician was contacted when the medication was unavailable, and the LPN was unsure if this step had been taken.
Failure to Monitor Blood Pressure as Ordered for Antihypertensive Medications
Penalty
Summary
A deficiency was identified when a resident's drug regimen was not kept free from unnecessary drugs due to a failure to monitor blood pressure as required by physician orders. The resident, admitted for rehabilitation with diagnoses including paralytic syndrome following cerebral infarction, hypertension, and other conditions, was prescribed three blood pressure medications: Isosorbide Mononitrate, Lisinopril, and Hydralazine. All three medications had physician-ordered parameters to hold administration if the blood pressure reading was less than 100. While the Medication Administration Record (MAR) showed blood pressure monitoring at 9 AM for Lisinopril, there was no documentation of blood pressure readings for the 2 PM and 9 PM doses of Hydralazine. Further review of the electronic medical record's vital sign section revealed inconsistencies in recording blood pressures at the times Hydralazine was administered in the afternoon and evening. During an interview, the RN unit manager and the Assistant Director of Nursing confirmed that the MAR did not include a space to record blood pressure readings for all medications requiring such monitoring, corroborating the surveyor's findings.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Facility staff failed to ensure that medication carts were kept locked when unattended, as observed during a complaint survey. On one nursing unit, a medication cart was found unlocked and unattended in a hallway while the nurse responsible was inside a resident's room with her back to the door, leaving the cart out of her line of sight. The surveyor was able to open the cart and found a cup containing pre-poured medications with no resident name labeled. The nurse later stated that the medications were for a resident who was unavailable due to therapy. Further inspection of the medication cart revealed multiple deficiencies in medication labeling and storage. Several opened medications, including inhalers and insulin pens, were not dated as required by manufacturer instructions. Additionally, insulin pens that required refrigeration were found in the cart without being refrigerated, despite being labeled with refrigerate stickers. The facility's own medication storage policy requires that only authorized personnel have access to medications and that multi-dose medications be dated upon opening, but these procedures were not followed.
Failure to Obtain Follow-Up Dental Services
Penalty
Summary
Facility staff failed to obtain follow-up dental services for a resident who had a diagnosis of dysphagia and experienced a significant weight loss of 12 pounds in one month. The resident reported not having properly fitting dentures, and this concern was communicated to the nurse manager, who was to follow up with the dentist for a refitting. The resident was later examined by a registered dental hygienist, who noted the resident's dental pain and desire for dentures, and documented that the dentist would see the resident on a scheduled date. However, the resident was not seen by the dentist as planned, and as of the time of the survey, the resident still had not received the necessary dental evaluation or services.
Failure to Provide Prescribed Diet Consistencies to Residents
Penalty
Summary
The facility failed to provide two residents with their prescribed diets in the correct consistency during a lunch observation. Both residents were documented as requiring mechanical soft, ground meat diets due to risks such as choking, swallowing difficulties, aspiration, weight loss/gain, and dehydration. However, during the meal service, one resident received cubed chicken parmesan instead of ground meat, and the other received meat in chunks rather than ground, as specified in their dietary orders. These discrepancies were directly observed by the surveyor, who also confirmed the dietary requirements by reviewing the residents' tray tickets and medical records. When the issue was brought to the attention of staff present in the dining room, it was acknowledged that the meat was not prepared as ordered, with staff stating that this was the usual practice. The Food Service Director and the cook both confirmed that the meats should have been ground according to the residents' dietary needs. The deficiency was further discussed with facility leadership, confirming that the prescribed diet consistencies were not provided as required.
Failure to Maintain Complete and Accurate Medical Records for a Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. A complaint was received alleging that the resident was often not fed due to short staffing, and that the resident's spouse had to visit to ensure the resident was fed. The resident had multiple diagnoses, including systemic lupus erythematosus, chronic pain, heart failure, muscle wasting, and a cognitive communication deficit. A review of the resident's medical record revealed significant gaps in the documentation of meal consumption by geriatric nursing assistants (GNAs). Specifically, there were multiple days across April, May, and June where documentation for breakfast, lunch, and/or dinner was missing. The missing records included both partial and full days without any entries, making it impossible to validate the amount of food the resident consumed. Facility leadership reviewed and agreed with the findings that the documentation was incomplete.
Failure to Arrange Hospice Services Upon Resident Request
Penalty
Summary
A deficiency was identified when the facility failed to arrange hospice services for a resident who requested them. The resident, who had a two-year history of cancer with metastasis to the brain and had recently completed unsuccessful radiation treatment, expressed a desire for hospice care along with their family. Documentation in the medical record showed that the primary care physician was informed and directed staff to contact hospice. However, there was no evidence in the medical record of a verbal order for hospice services following this request, nor was there documentation of any action taken to initiate hospice care until nearly two weeks later, when the resident was seen for pain management and a palliative care consult was ordered. Interviews with facility staff revealed inconsistencies and confusion regarding the process for initiating hospice services. The Assistant Director of Nursing stated that requests for hospice are communicated to social work, who then contacts hospice, but the Director of Social Services indicated that sometimes orders were not consistently relayed. The resident was ultimately discharged home with hospice services arranged to begin upon arrival, but the facility did not arrange for hospice services during the resident's stay despite the explicit request and physician direction.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing data at the beginning of each shift, including the total number and actual hours worked by nursing staff. Upon entry to the facility's lobby and on both nursing units, there was no visible signage displaying the names or hours of nursing staff working in the building. Observations revealed that the only available information was an outdated dry erase board on one unit, listing staff names from a previous date, and another board that listed names but not hours. Multiple observations confirmed the absence of required postings over two days. Interviews with the Assistant Director of Nursing and the Human Resources Director confirmed that the staffing information had not been posted, with the ADON attributing this lapse to the scheduler's absence and the HR Director acknowledging responsibility for posting the hours during this period.
Failure to Conduct and Document Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct and document timely care plan meetings for several residents, as evidenced by the review of clinical records and staff interviews. Resident #46 had a care plan conference upon admission, but no subsequent meetings were documented, and there was no evidence of invitations to care plan meetings. The Social Work Director confirmed the lack of meetings and documentation. Similarly, Resident #4's records showed the last care plan conference was held months ago, with no evidence of required subsequent meetings. The Director of Nursing and Assistant Director of Nursing were unable to provide clarification or documentation for these missing meetings. Resident #69 reported not having care plan meetings, and a review of their electronic medical record revealed no documentation of such meetings or care conference notes, despite multiple MDS assessments being completed. The Social Worker, responsible for setting up these meetings, confirmed the process but failed to provide evidence of completed meetings. The Administrator later provided a care conference note, but it was insufficient to cover the required meetings following the MDS assessments. Resident #21's care plan meeting was initially scheduled but canceled due to the Social Work Director's unavailability and was not rescheduled in a timely manner. The resident's medical record lacked evidence of a completed care plan meeting, and the Social Work Director admitted to not documenting the meeting notes or summary. The deficiency in timely care plan meetings and documentation was evident across multiple residents, indicating a systemic issue in the facility's care planning process.
Facility Fails to Maintain Safety and Security
Penalty
Summary
The facility failed to maintain a safe environment for its residents, as evidenced by multiple observations and interviews. Resident #4, who had a care plan to address fall risks, was repeatedly observed with their bed in a high position, contrary to the care plan's directive to keep it in a low position. Despite being informed, the nurse did not lower the bed. Additionally, Resident #14's room was found with debris on the floor, including food trays and a catheter bag, which posed a hazard. The fall mat intended for safety was not in place, and staff failed to address these issues promptly. The facility also failed to secure medication carts, as observed when a cart was found unlocked and accessible. A nurse was informed and locked the cart, but this incident highlighted a lapse in maintaining medication security. Furthermore, the facility did not implement adequate measures to secure building doors and patio gates after hours. Surveyors were able to enter the facility through multiple unlocked doors without alarms or staff presence, indicating a significant security breach. Interviews with staff confirmed that the keypad locks had been non-functional for months, and no alternative security measures were in place. The Administrator acknowledged the broken locks but had not taken steps to replace them or ensure staff used secure entry points. The lack of response to the identified security risks and the failure to lock the patio gate further demonstrated the facility's inability to protect residents from potential hazards. These deficiencies were evident for two residents, a medication cart, and multiple building entrances during the survey.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a surveyor's inspection. In the kitchen's dry food storage area, several opened and unlabeled food items were found, including a 25lb bag of sugar, flour, and whole grain brown rice stored in large containers on the floor. Additionally, an opened and unlabeled jug of teriyaki sauce, a container of mashed potatoes, soy sauce, peanut butter, and an expired bag of pancake mix were found on a shelving unit. In the walk-in refrigerator, the surveyor noted opened and unlabeled bags of salad, spinach, sliced onions, boiled eggs, bologna, walnut topping, and various other food items, some of which were expired. The walk-in freezer contained opened and unlabeled tubs of ice cream, sliced pepperoni, egg rolls, and mixed vegetables. The Certified Dietary Manager (CDM) was unaware of the facility's food safety and storage policy, which was later reviewed and indicated that packaged foods should be dated when opened and leftovers labeled and discarded after three days. Despite being informed of the deficiencies, the facility did not remove or discard the identified food items from the storage areas. The surveyor's findings were confirmed by the CDM, and the facility's failure to adhere to its food safety and storage policy was evident, as the unlabeled and expired food items remained in the kitchen, posing a potential risk to all residents consuming food prepared in the facility.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that the call light system was available, functional, and operational for all residents, as observed during a recertification survey. Six residents were identified as lacking access to a working call light system. For instance, Resident #15's call light was unplugged and out of reach, and the resident reported it had been broken for several days. Similarly, Resident #8's call light did not function, and the resident had stopped using it due to staff non-responsiveness. These issues were not isolated, as other residents, such as Resident #18 and Resident #22, also experienced non-functional call lights, with no alternative devices provided. The maintenance log review revealed discrepancies in the documentation of repair requests. Although Resident #15's call light was reported and repaired, there were no maintenance requests logged for Residents #8, #18, #22, and #36. Additionally, Resident #18's shared bathroom lacked a call light device, and no request for installation was documented. Interviews with staff, including the Unit Manager and Maintenance Director, confirmed the lack of awareness and documentation regarding these issues. The Maintenance Director noted that the facility's protocol was to provide hand bells when call lights were under repair, but this was not consistently implemented. The surveyors' findings highlighted a systemic issue with the facility's call light system, affecting multiple residents' ability to summon assistance. Despite the facility's protocol for alternative devices, such as hand bells, these were not provided to the affected residents. The lack of functional call lights and alternative methods for residents to communicate their needs to staff was a significant deficiency observed during the survey.
Failure to Offer Showers to Resident
Penalty
Summary
The facility staff failed to ensure that residents are offered two showers each week, as evidenced by the case of one resident out of a sample of 56. The resident, identified as Resident #28, reported during an interview that they have only received bed baths and have not had a shower in two years, despite expressing a preference for showers. A review of the resident's clinical record confirmed that only bed baths have been documented since the beginning of the year. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the resident was initially informed that they needed to request showers, and it was believed that the resident preferred to refuse showers. However, there was no documentation of such refusals in the resident's chart, which the DON acknowledged should have been recorded. The DON stated that the resident's care plan included the right to refuse, but agreed that nursing staff should document refusals.
Failure to Offer Advance Directives to Residents
Penalty
Summary
The facility staff failed to ensure that residents were offered the opportunity to complete Advance Directives upon admission. This deficiency was identified during a clinical record review and staff interview, affecting three out of nine residents reviewed for Advance Directives. Specifically, the clinical records of these residents did not contain an Advance Directive, nor was there evidence that they had been offered the opportunity to complete one. The absence of documentation indicates a lapse in the facility's process for managing Advance Directives. During an interview, the Social Work Director explained that upon admission, a Maryland Order for Life Saving Treatment (MOLST) is completed by the primary physician, and residents are asked if they have an Advance Directive. If they do not, they are given a copy to complete. However, the Social Work Director was unsure about the documentation process and acknowledged that the social work histories might not have been completed due to staffing changes. This lack of documentation and follow-through contributed to the deficiency, as there was no further evidence provided to show that residents or their responsible parties were given the opportunity to complete an Advance Directive.
Failure to Maintain Resident's Medical Information Confidentiality
Penalty
Summary
The facility nursing staff failed to maintain the confidentiality of a resident's medical information. During an observation of medication administration, a staff member left a medication packet on top of a locked medication cart while entering a resident's room. The packet, which was visible, contained the resident's name and a list of their medications, including risperidone, Eliquis, Lasix, and potassium chloride. This incident involved one resident out of a sample of 56 and was observed by surveyors during their assessment of the facility's practices.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents or their representatives regarding hospital transfers, as required by their Discharge Notification Policy. This deficiency was identified during the annual survey's investigative portion, where it was found that two residents were transferred to the hospital without proper written notification. Resident #69 was transferred due to a dislodged Foley catheter with bleeding and returned after five days, while Resident #35 was transferred twice, once for altered mental status to rule out a stroke and another time for hypoxia, with no written notifications provided for these transfers. The surveyor's review of the electronic medical records and physical charts revealed the absence of documentation indicating that the residents, their representatives, or the Ombudsman were notified in writing about the hospital transfers. During an interview, the Director of Nursing was informed of this concern, and the Social Worker later provided copies of the Transfer/Discharge Notification forms. However, it was confirmed that these forms were not given to the residents, their representatives, or the Ombudsman, as required by the facility's policy.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility staff failed to develop baseline care plans for residents, as evidenced by the case of one resident out of six reviewed. The clinical record review revealed that the resident was admitted on a specific date and had care plan conferences on two subsequent dates. However, a baseline care plan, which should have been created within 48 hours of admission, was not present in the clinical record. Additionally, there was no comprehensive care plan within the same timeframe. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), they were informed of the absence of a baseline care plan, but no explanation was provided, nor was a baseline care plan shown to the surveyor before the exit.
Deficiency in Resident-Centered Activity Programs
Penalty
Summary
The facility staff failed to ensure that residents had the opportunity to participate in an activity program and did not provide an ongoing resident-centered activities program to improve or maintain the residents' mental and psychosocial well-being. This deficiency was evident for three out of five residents reviewed for activities. Resident #28 expressed uncertainty about being encouraged to leave their room and mentioned a preference for music. The Activities Director admitted to being backlogged with documentation and noted that the resident often refused activities after a short period. Observations revealed that the resident's television or radio was not on, despite claims that the television was turned on daily. Resident #46's family member reported that the resident was often in bed and believed activities were not brought to the resident. The last activity assessment for this resident was dated several months prior, with no evidence of activities being provided. The Activities Director claimed the resident enjoyed certain activities, but the survey team did not observe the resident outside the room or the television being on. The Administrator acknowledged missing documentation after being shown the clinical records. Resident #6 was observed in their room with a shared television on at a high volume, but no communication devices were present. The resident's Minimum Data Set (MDS) indicated preferences for books, music, and animals, but these were not assessed in recent years. Activity documentation was sparse and lacked specificity, failing to reflect personal activities or interests. The Activities Director stated efforts to engage residents daily, but the surveyor noted the absence of activity materials in the resident's room.
Failure to Reposition Resident
Penalty
Summary
The facility staff failed to ensure that a resident was repositioned to maintain or improve their range of motion and mobility. This deficiency was observed in one resident, who was repeatedly seen lying on their back in bed over several days. Specifically, the resident was observed on their back on four separate occasions: once on April 16, 2024, at 11:46 AM, again on April 18, 2024, at 1:54 PM while being fed lunch, on April 23, 2024, at 2:15 PM, and finally on April 24, 2024, at 12:30 PM. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unable to provide an explanation for the resident's positioning when interviewed on April 30, 2024, and stated they would investigate the matter.
Inadequate and Unvaried Dietary Provisions
Penalty
Summary
The deficiency involves inadequate and unvaried dietary provisions for residents, as identified through interviews and observations. Resident #30 reported that the food is consistently cold, with limited entree choices, and occasional unavailability of salad ingredients. This resident was observed to keep a personal stash of breakfast cereal due to hunger concerns. Resident #28 expressed dissatisfaction with the lack of variety in breakfast options and unfulfilled food preferences. Staff #8, a cook, confirmed the existence of a standard breakfast menu with limited alternatives and acknowledged issues with food supply and delivery, leading to insufficient food availability.
Deficiencies in Record Management and Confidentiality
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain complete medical records for two residents during the annual survey. For one resident, personal information was incorrectly placed in another resident's clinical record. This breach of confidentiality was identified during a review of the clinical records, where the Physician Order Report of one resident was found in the wrong file. This error was brought to the attention of the facility nursing staff. Additionally, the facility did not ensure the completeness of medical records by failing to void an outdated Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form when a new one was completed for another resident. The surveyor discovered two MOLST forms in the resident's paper medical record, with conflicting orders regarding CPR. The presence of both forms could lead to confusion about the resident's current code status, as the nursing staff relies on the MOLST in the paper record to determine this. The outdated MOLST had not been voided as per the facility's procedure, which requires drawing a diagonal line through the old form and marking it as VOID.
Infection Control Deficiencies Observed During Survey
Penalty
Summary
The facility staff failed to adhere to proper infection control practices during the annual survey, as evidenced by three separate observations. Firstly, a certified medication aide did not wash hands or use hand sanitizer before administering medications and used Ocusoft eyelid cleanse wipes without gloves. Secondly, a nurse entered a room with a poster instructing the use of hand sanitizer before entry but instead washed her hands in the bathroom sink, neglecting the posted instructions. Lastly, a resident's catheter bag was observed on the floor on two separate occasions, and two nurses entered the room without raising the catheter bag off the floor.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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