Fayette Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 1217 West Fayette Street, Baltimore, Maryland 21223
- CMS Provider Number
- 215183
- Inspections on file
- 19
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Fayette Health And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to thoroughly investigate an allegation that a resident’s money was stolen by a GNA. When the resident reported that $150.00 was missing and implicated a specific GNA, the facility’s investigation relied solely on standardized abuse interview forms that asked only about verbal, physical, or sexual abuse, and all responses were marked negative. No residents, including the reporting resident’s roommate, were asked about missing property, prior incidents of missing belongings, or concerns related to the implicated GNA. The DON later confirmed that only the abuse questionnaires were used and that residents were not questioned about the specific allegation of theft because those were the forms they had been told to use.
A resident with Type 2 DM had a physician order for a CCD with no salt packet, and documented allergies to shellfish-derived products and caffeine, along with no juice and no milk restrictions, all clearly listed on the tray ticket and care documents. After the resident declined their original lunch tray, a GNA, without checking the ticket, offered and delivered a shrimp scampi tray at the resident’s request and did not consult a nurse, despite a surveyor pointing out the shellfish allergy. The GNA also attempted to provide apple juice from the cart and stopped only when the surveyor drew attention to the no-juice restriction, while the Dietary Manager confirmed that residents with seafood or shellfish allergies should have received a substitute entrée instead of shrimp scampi.
Staff failed to document insulin administration in real time for a resident receiving multiple scheduled insulin types, including Aspart, Lispro, and Glargine. Review of the MAR and electronic time stamps showed numerous insulin doses recorded between nearly 2 and over 6 hours after scheduled times, and some afternoon and bedtime Lispro doses documented as given at the same time on multiple days, with no explanatory notes. The acting DON could not provide additional documentation, and interviewed RNs admitted they often administered insulin on time but delayed electronic MAR entry, sometimes recording doses on paper and signing them off later, resulting in inaccurate electronic time stamps.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
The facility staff failed to ensure that residents received showers at least twice a week, as required. Multiple residents reported not receiving showers, and clinical records confirmed the lack of showers. Staff interviews revealed misunderstandings and lack of documentation regarding residents' shower schedules and refusals.
The facility failed to ensure the accuracy of MOLST and maintain proper advance directives for several residents. For example, one resident's MOLST form contained errors, and another resident had no documentation of a MOLST or advance directive despite residing at the facility for over 11 months. The Social Worker admitted to not routinely asking residents if they wanted to complete an advance directive.
The facility failed to hold timely care plan meetings with an interdisciplinary team for three residents, as required by the MDS assessment schedule. One resident reported never being invited to a care plan meeting, another had no documented meetings since 2020, and a third had not had a meeting since admission.
The facility failed to safeguard resident-identifiable information and maintain accurate medical records. An unattended medication cart displayed a resident's medication profile, and several instances of inaccurate documentation were found, including incorrect notes about dialysis, dressing changes, and medications. Additionally, a resident did not receive prescribed medications, yet the LPN documented that they were administered.
The facility failed to sanitize medical equipment between residents and did not maintain gown availability for Enhanced Barrier Precautions (EBP). A CMA used a blood pressure monitor on two residents without sanitizing it, and rooms with EBP signs lacked gowns. Staff interviews revealed a lack of awareness and proper procedure for obtaining gowns.
The facility failed to notify residents and their representatives in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified for four residents, with medical records lacking documentation and staff interviews confirming the policy was not provided as required.
The facility failed to accurately document MDS assessments for four residents, including errors in recording dialysis dependence, tobacco use, mental health diagnoses, and assistance levels for a resident with bilateral above-knee amputations. These inaccuracies were confirmed through medical record reviews and staff interviews.
The facility failed to provide proper wound care for four residents, resulting in inconsistent and inaccurate documentation, lack of supervision, and missing wound care orders. The staff acknowledged the deficiencies but did not provide additional information or corrective actions.
The facility staff failed to ensure the privacy and confidentiality of residents' personal and medical information. A discharge summary and PASRR form for one resident were incorrectly placed in another resident's clinical record. The Administrator confirmed the error during an interview.
The facility failed to protect residents from verbal abuse in two separate incidents. In one case, an RN used profane language and was dismissive towards a resident. In another case, a video of a staff member verbally abusing a resident was circulated online, leading to the staff member's termination.
The facility staff failed to ensure resident dignity as evidenced by staff not wearing name tags and using personal cell phones during resident care. One GNA and one RN were observed without name tags, and another GNA was seen using a personal cell phone while assisting a resident with lunch.
The facility failed to ensure that a resident's personal property was not lost. Despite the resident reporting missing clothes to multiple staff members, no grievance forms were found, and the personal inventory sheet was missing from the resident's chart. The Housekeeping Supervisor suggested the clothes might have been mistakenly donated, and the NHA only completed a grievance form after the surveyor's intervention.
The facility failed to report a reasonable suspicion of abuse resulting in serious bodily injury within the required 2-hour timeframe. A resident complained of right hip pain and mentioned a fall three days prior. An x-ray confirmed a hip fracture, and the resident was transferred for urgent surgery. The initial self-report was delayed by 2 days and 7 hours, violating reporting requirements.
The facility failed to provide written notice with the reason for transfer to residents and failed to notify the Ombudsman of residents that transferred. This deficiency was identified in three residents who were hospitalized, with staff providing only verbal notifications and no written notices.
The facility failed to develop and provide a baseline care plan for two newly admitted residents within 48 hours of their admission. For one resident, the nursing evaluation did not indicate that care planning was discussed or that the resident received a summary, and it lacked documentation of planned therapy services, goals, and a summary of medications with dietary instructions. The Nursing Home Administrator did not provide additional information by the time of the surveyor's exit.
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. One resident's smoking habits were not addressed in the care plan, another resident's discharge planning was overlooked, and a third resident's incontinence was not managed according to their care plan. The Nursing Home Administrator acknowledged these deficiencies during the surveyors' visit.
The facility staff failed to ensure that a resident's toenails were cut, resulting in a long toenail on the big toe of the right foot. The resident reported that no one had cut the toenails even after dressings were changed, and the issue persisted for several days.
The facility failed to provide an activities program that meets the interests and needs of residents based on their comprehensive assessments and care plans. Two residents expressed preferences for specific activities, but the documented activities were minimal and did not align with their stated interests. The Administrator and Regional Clinical Director acknowledged the deficiency when shown the activity logs.
The facility failed to maintain a medication error rate of 5% or less. A CMA did not administer Vitamin D to a resident as ordered and incorrectly documented it as given. Additionally, the CMA administered Levothyroxine to another resident after breakfast, contrary to the order specifying it should be given before breakfast. The error rate was found to be 8%.
The facility failed to secure medication and treatment carts, as observed during random tours. Unlocked carts containing medications and medical supplies were found on the 1st and 3rd floors. Staff confirmed the carts should have been locked when unattended.
The facility staff failed to assist a resident in making necessary appointments for dental care or treatment. Despite a dentist's recommendation for extractions, no extractions were performed during subsequent visits, and no further appointments were scheduled. The resident, who had only three teeth left and reported gum pain, did not receive the necessary dental care.
The facility failed to employ an LPN in accordance with Maryland State laws. The LPN had an active Virginia license but lacked necessary documentation and currently resides in Maryland. The NHA confirmed awareness of the licensing requirement and informed the LPN to apply for a Maryland license.
The facility failed to ensure that residents' bed mattresses were properly secured to the bed frames, leading to safety concerns. This deficiency was observed in two residents, one with a history of falling and another with bilateral amputation, both requiring assistance with transfers and moving in bed. The Maintenance Director acknowledged the issue but failed to resolve it promptly.
The facility failed to maintain an effective pest control program, as evidenced by multiple gnats swarming in a resident's room. The DON confirmed the infestation and reported it to the NHA, who was initially unaware of the issue. Pest logs showed prior extermination treatments for gnats.
The facility failed to ensure required in-service training for nurse aide staff was completed, specifically for a Geriatric Nursing Assistant hired in October 2023. Despite using computer-based training programs and messaging systems, the facility could not provide documentation of the necessary training, revealing a deficiency in monitoring and record-keeping.
The facility failed to inform a resident's representative of changes to the care plan, leading to confusion about who should be contacted for decisions. Despite evaluations indicating the resident's incapacity, the social history assessment incorrectly listed the resident as having decision-making capacity, resulting in inconsistent notifications to the resident and their ex-spouse.
Failure to Thoroughly Investigate Allegation of Missing Resident Money
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an allegation of missing money involving a resident and a Geriatric Nursing Assistant (GNA). On 2/21/26, a resident reported that $150.00 had been stolen by GNA #8. The facility’s investigation documentation consisted of seven Resident Interview forms that only addressed abuse-related questions (verbal, physical, or sexual), all of which were checked “No,” indicating the residents denied being abused or witnessing abuse. There was no evidence that any residents, including the reporting resident’s roommate, were interviewed about missing property or money, prior experiences with missing belongings, or any concerns specifically related to GNA #8. During an interview on 4/9/26 at 1:35 PM, the DON confirmed to the surveyor that the abuse questionnaire forms were the only interviews conducted as part of the investigation. The DON acknowledged that the reporting resident’s roommate was not asked whether they had witnessed or had any knowledge of the alleged theft of money. When asked why residents were not questioned about issues specific to the allegation of missing money, the DON stated that “that’s what we were told to use,” referring to the abuse questionnaire forms, demonstrating that the investigation did not address the specific allegation of theft.
Failure to Follow Documented Allergies and Diet Restrictions During Meal Service
Penalty
Summary
Facility staff failed to provide food that accommodated a resident’s documented allergies, diet order, and restrictions. The resident had Type 2 Diabetes and a physician’s order for a carbohydrate controlled diet with regular texture, thin liquids, and no salt packet. The medical record, plan of care, and GNA Kardex all documented allergies to shellfish-derived products and caffeine, as well as restrictions of no juice and no milk. On the survey date, the resident reported not eating lunch because they did not like the meal provided. Their declined tray ticket clearly listed the carbohydrate controlled diet, shellfish and caffeine allergies in bold, and the no salt packet, no juice, and no milk restrictions. Later, a GNA was observed at the doorway with the meal cart and asked the resident’s roommate why they had not eaten their shrimp scampi. Upon hearing this, the resident stated they wanted shrimp scampi as well. The GNA took another tray containing shrimp scampi from the cart and, without reviewing the resident’s tray ticket for diet, restrictions, or allergies, offered it to the resident. A surveyor intervened and pointed out the documented shellfish allergy on the ticket, but the GNA proceeded to deliver the shrimp scampi tray to the resident and did not refer the request to a nurse. The GNA then picked up a cup of apple juice from the cart to take to the resident and only stopped when the surveyor called attention to the resident’s no-juice restriction printed on the ticket. The Dietary Manager later confirmed that shrimp scampi was the main entrée and that residents with seafood or shellfish allergies should have received a substitute entrée of country fried steak.
Failure to Document Insulin Administration in Real Time
Penalty
Summary
Facility staff failed to document insulin administration in real time and in accordance with accepted professional standards and practices for one resident. The resident had physician orders for multiple insulins: Insulin Aspart 7 units before meals at 6:00 AM, 11:00 AM, and 4:00 PM; Insulin Lispro before meals and at bedtime at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM with dosage based on blood sugar readings; and Insulin Glargine 20 units at bedtime. Review of the April 2026 MAR and associated electronic time stamps for doses administered between 4:00 PM on 4/3/26 and 11:00 AM on 4/13/26 showed that 19 of 80 insulin doses were signed as administered between 1 hour 50 minutes and 6 hours 38 minutes after the scheduled administration time, outside the standard of administering time-critical medications such as insulin within 30 minutes before or after the scheduled time. There was no documentation in the medical record explaining these deviations from scheduled administration times. Further review showed that the 4:00 PM and 8:00 PM Insulin Lispro doses were documented as being administered at the same time on three separate dates, without any explanatory documentation. During interviews, the acting DON was unable to provide additional documentation or explanation for the late or overlapping time stamps. Two of the four nurses responsible for the late insulin documentation reported that they did not consistently chart insulin administration at the time it was given. One RN stated that she administers insulin on time but does not always sign it off as she gives it, acknowledging she knows better than to do that. Another RN reported that he sometimes writes administration times on paper and enters them into the electronic MAR later, and stated that he did not actually administer two doses of the same insulin together as the documentation suggested, indicating that the time stamps reflected delayed documentation rather than the actual time of administration.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility staff failed to ensure that residents received showers at least twice a week, as required. This deficiency was identified through interviews with residents and staff, as well as clinical record reviews. Resident #81 reported not having had a shower in three days and only receiving bed baths in February and March. The Unit Manager acknowledged the issue but had not taken action. Resident #111 also reported not receiving showers, and although a nurse claimed the resident was scheduled for showers, there was no documentation to support this. Resident #116 stated they had only one shower in the last 30 days, and their clinical records confirmed the lack of showers. The Unit Manager incorrectly assumed the resident was independent and chose not to shower, despite no documentation of refusal in the clinical records. Resident #28 reported receiving only two showers since admission a year ago. Clinical records showed the resident received bed baths but not showers, except for one tub bath. The resident's assigned GNA confirmed the lack of routine showers, and there was no documentation of the resident refusing showers. The Nursing Home Administrator and Regional Director of Operations confirmed that residents should receive showers twice a week and that GNAs are expected to document this on the ADL flow sheet. However, this expectation was not met, leading to the deficiency.
Failure to Ensure Accuracy of MOLST and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) and to maintain proper advance directives in the residents' medical records. This deficiency was evident for seven out of nine residents reviewed. For instance, Resident #27's legal contact person could not recall if a completed MOLST or advance directive was provided upon admission. The facility's internal face sheet section was used instead, leading to an error in the MOLST form, which incorrectly stated that the resident was mentally competent and had given informed consent. Additionally, the Social Worker admitted that the MOLST and advance directive were not obtained during the admission period, and a blank form was only sent out after the surveyor's intervention. Similarly, Resident #64 had resided at the facility for over 11 months without proper documentation of a MOLST or advance directive. The Social Worker confirmed that these documents were not completed and relied on the internal face sheet section instead. Resident #61's clinical record also lacked an advance directive, and the Social Worker admitted that they do not routinely ask residents if they want to complete one. Resident #111's record showed no advance directive, and although the resident was aware of it, there was no evidence that the facility staff offered assistance in its completion. These findings were communicated to the Administrator and the Regional Director of Clinical Operations, who acknowledged the issues but did not provide immediate corrective actions.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This deficiency was evident for three residents. Resident #97 reported never being invited to a care plan meeting. The Social Worker Assistant, responsible for planning these meetings, admitted to not being up-to-date on conducting care plan meetings and could not provide any progress notes for Resident #97's care plan meetings. The Social Worker overseeing the assistant was unaware of the backlog and confirmed the deficiency upon review. Resident #33 did not recall having a care plan meeting, and record reviews confirmed that no care plan meetings had been documented since January 2022. The Social Worker confirmed that the last care plan meeting for this resident was in 2020. Resident #81 also reported not having had a care plan meeting since admission and had not seen the Social Worker. The requested care plan attendance sheets were not provided before the exit conference, further indicating a lapse in the facility's care planning process.
Failure to Safeguard Resident Information and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with acceptable professional standards and practices by not safeguarding resident-identifiable information and keeping accurate documentation. An unattended medication cart with a computer displaying a resident's medication profile was observed, exposing sensitive information to the public. The involved staff acknowledged the issue but did not take appropriate measures to prevent it from happening again. Inaccurate documentation was also found in the medical records of several residents. One resident's record incorrectly noted that they were escorted to dialysis, which the interim Director of Nursing confirmed was an error. Another resident's Treatment Administration Record showed a dressing change as completed when it had not been done, and the resident confirmed that they no longer had a toe wound. Additionally, another resident's progress notes inaccurately documented the presence of medical devices and medications, which staff attributed to errors in the electronic medical record system. Furthermore, a resident did not receive four prescribed medications because they were not available in the medication cart, yet the LPN documented that the medications were administered. The LPN later admitted that the medications were not obtained, and the Nursing Home Administrator and Director of Nursing were informed of the discrepancy. The medications were eventually located and administered, but the initial failure to provide them and the inaccurate documentation were significant issues.
Infection Control and PPE Availability Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitization of medical equipment between residents and did not maintain the availability of gowns for Enhanced Barrier Precautions (EBP). During a medication administration observation, a Certified Medication Aide (CMA) used a blood pressure monitor with a wrist cuff on two different residents without sanitizing the equipment between uses. The CMA acknowledged the failure to sanitize the equipment and stated that the facility's expectations were to sanitize all shared medical equipment after each use and between each resident. The Director of Nursing (DON) confirmed that it is expected of all nursing staff to sanitize medical equipment between residents with sanitizing wipes. Additionally, the facility did not ensure that gowns were available for staff use as required by EBP signage posted on certain rooms. Observations revealed that rooms with EBP signs did not have gowns stocked in the wall caddies or on a cart outside the rooms. Interviews with staff indicated a lack of awareness and proper procedure for obtaining gowns. The Unit Manager, Regional Director of Clinical Operations, and Infection Control Nurse were shown the deficiency, and supplies were subsequently obtained and stocked. The Infection Control Nurse confirmed that staff are expected to wear gloves and gowns for direct resident care under EBP, and the DON acknowledged the issue with gown availability and stated that efforts were being made to educate staff and maintain supplies.
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 are notified in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified for four residents during the annual survey. For Resident #16, there was no documentation that the bed hold was offered upon transfer to the hospital, and interviews with LPNs revealed that they did not offer or document the bed hold policy. The Nursing Home Administrator confirmed the expectation for staff to offer and document bed holds but could not locate any evidence of this for Resident #16's transfer on 3/6/24. For Resident #63, the medical record review showed no documentation that the bed hold policy was provided upon transfer to the hospital. Interviews with RN #4 and the Director of Nursing revealed that the bed hold policy is reviewed only during the admissions process and not provided in writing at the time of transfer. The Social Worker and Administrator confirmed that the nursing staff should offer a written copy of the bed hold policy when the resident is transferred out of the facility, but this was not done for Resident #63. Similarly, Resident #109's medical record lacked documentation of the bed hold policy being provided upon transfer to the hospital. Interviews with RN #4, the Director of Nursing, and the Social Worker indicated that the bed hold policy is not reviewed or provided in writing at the time of transfer. The Administrator confirmed that the policy should be offered in writing but was not done for Resident #109. For Resident #117, there was no documentation that the bed hold policy was provided at the time of transfer to the hospital, and the Administrator and Regional Clinical Director did not dispute the findings or provide any evidence of notification.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document resident assessments on the Minimum Data Set (MDS) for four out of six residents reviewed. Resident #16 had a diagnosis of End Stage Renal Disease and was dependent on dialysis, but the MDS assessment did not indicate that the resident received dialysis. Resident #28's MDS assessment incorrectly documented that the resident did not use tobacco, despite multiple smoking assessments indicating nicotine use. Resident #24's MDS assessment did not reflect active diagnoses of depression and anxiety disorder, although the resident was receiving antianxiety and antidepressant medications. Resident #13, who had bilateral above-knee amputations, was incorrectly coded as requiring maximal assistance for putting on/off footwear, despite not having prostheses. These inaccuracies were confirmed through medical record reviews and staff interviews. The Nursing Home Administrator and Lead MDS Coordinator acknowledged the errors upon review. The discrepancies in the MDS assessments indicate a failure in accurately documenting the residents' health status and functional capabilities, which is essential for providing appropriate care and treatment.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide wound care treatments according to professional standards for four residents. Resident #101's significant other was performing wound care without supervision from the facility's wound nurse, who had not been present for several weeks. The care plan required daily evaluation of the wounds, but no documentation of wound assessments was found after the wound nurse left. The facility's staff confirmed that the nurses were expected to provide wound care, but there was a lack of documentation and assessment in the medical records. Resident #21 had an order for daily assessment of a left ankle wound, but the Treatment Administration Record (TAR) showed inconsistent and inaccurate documentation. The resident reported pain and signs of infection, but the TAR did not reflect these observations accurately. The Regional Director of Clinical Operations acknowledged the concern but did not provide additional information. Resident #332 had a right hand wound that was not documented in the medical record, and no wound care order was found. The wound Nurse Practitioner confirmed that there should have been an order for the wound care. Additionally, Resident #74 had multiple instances of undocumented wound care dressing changes, with the Director of Nursing acknowledging the missing documentation and stating that staff would be educated on wound care requirements.
Failure to Maintain Confidentiality of Resident Records
Penalty
Summary
The facility staff failed to ensure the privacy and confidentiality of residents' personal and medical information. During a review of clinical records, it was discovered that a discharge summary and Preadmission Screening and Resident Review (PASRR) form for one resident were incorrectly placed in another resident's clinical record. This error was identified for one resident out of a sample of 48 residents. The Administrator confirmed that the personal information should not have been in the other resident's record during an interview.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by two separate incidents involving two residents. In the first incident, a resident alleged that a Registered Nurse (RN) used profane language and was dismissive when the resident complained about a cold room. The RN admitted to using profanity and being dismissive, but the Nursing Home Administrator (NHA) concluded that the allegation was unsubstantiated due to a perceived lack of intent. The resident did not recall the incident but described the staff as rude. The RN received abuse training following the incident. In the second incident, an anonymous caller informed the Administrator about a video circulating online that showed a staff member verbally abusing a resident. Although no staff members witnessed the abuse, the video was verified, and the staff member involved was terminated. The resident involved did not feel disrespected, and staff education on abuse was conducted. The Director of Nursing (DON) confirmed that another resident had recorded and posted the video, which was later taken down.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility staff failed to ensure the dignity of the residents as evidenced by two specific incidents. First, on 3/18/24, a Geriatric Nursing Assistant (GNA) on the 3rd floor nursing unit was observed without a name tag. When questioned, the GNA acknowledged that the expectation was to wear a name tag at all times and subsequently wrote her name on a piece of tape and placed it on her uniform. Similarly, on 3/20/24, a Registered Nurse (RN) was observed without a name tag after exiting a resident's room. The RN confirmed that the expectation was to wear a name tag at all times. Second, on 3/19/24, another GNA was observed using a personal cell phone while assisting a resident with their lunch. This GNA was also not wearing a name tag and admitted that the facility's policy prohibited cell phone use in resident rooms and required name tags to be worn at all times.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
The facility failed to ensure that personal property was not lost for Resident #28. During an initial tour, Resident #28 reported missing clothes and stated that he/she had informed multiple staff members, including nurses, the Social Service Director, and the Nursing Home Administrator (NHA), about the issue. Despite these reports, no grievance forms were found for Resident #28 regarding the missing items. The surveyor's review of the resident's physical chart also revealed the absence of a personal inventory sheet. Interviews with staff confirmed that the inventory sheet should be in the physical chart, but it was not located. The Social Service Director acknowledged awareness of the missing items and mentioned that the Housekeeping Supervisor was searching for them. However, the NHA was initially unaware of the issue and had not completed a grievance form until prompted by the surveyor. The Housekeeping Supervisor later provided a list of missing items and suggested that the resident's clothes might have been mistakenly donated. The NHA eventually completed a grievance form for the missing items, but this was done only after the surveyor's intervention. The deficiency was further highlighted by the facility's inability to locate Resident #28's personal inventory sheet and the lack of timely grievance documentation. The Housekeeping Supervisor's belief that the resident's clothes were mistakenly donated underscores a lapse in the facility's procedures for handling personal property. The NHA's delayed response and lack of initial awareness of the issue indicate a breakdown in communication and follow-up within the facility. This series of actions and inactions led to the failure to safeguard Resident #28's personal property, resulting in the resident's ongoing distress and inconvenience.
Failure to Timely Report Suspected Abuse Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to report a reasonable suspicion of abuse resulting in serious bodily injury within the required 2-hour timeframe to the State Agency. This deficiency was identified in the case of a resident who complained of right hip pain on 12/4/23 at 10:49 PM, after returning to their room in a wheelchair. The resident informed the nurse that they had fallen three days prior but had not reported it. An x-ray ordered on 12/5/23 confirmed a right hip intertrochanteric fracture, and the resident was subsequently transferred to a community hospital for urgent surgery on 12/6/23. The initial self-report of the incident was not sent to the State Agency until 12/6/23 at 5:45 PM, which was 2 days and 7 hours after the facility staff became aware of the reasonable suspicion of serious bodily injury. The Administrator confirmed that the facility staff were aware of the incident on 12/4/23 at 10:49 PM, but the delay in reporting violated the requirement to report such incidents within 2 hours. This failure to timely report the incident was evident during the review of the facility's self-report file and interviews with the staff and Administrator.
Failure to Provide Written Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide written notice with the reason for transfer to residents and failed to notify the Ombudsman of residents that transferred. This deficiency was identified in three residents who were hospitalized. Resident #332 was transferred to the hospital in early February 2024, but there was no written notice provided to the resident, and the transfer was not included in the list sent to the Ombudsman. The Nursing Home Administrator acknowledged that only discharges, not transfers, were sent to the Ombudsman for the month of February 2024. Resident #63 was transferred to the hospital due to abdominal pain and vomiting, but there was no documentation that the resident or their representative received written notice of the transfer. Similarly, Resident #109 was transferred to the hospital due to the facility not having appropriate respiratory equipment, but there was no written notice provided to the resident or their representative. Interviews with staff revealed that verbal notifications were given, but written notices were not provided, and no evidence of written notices was presented during the exit conference.
Failure to Develop Baseline Care Plan for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and provide a baseline care plan for two newly admitted residents within 48 hours of their admission. For Resident #125, admitted in late January 2024, the medical record review revealed no baseline care plan note. Although a nursing evaluation was completed on 1/24/24, it did not indicate that care planning was discussed with the resident or that the resident received a summary. The evaluation also lacked documentation of the therapy services planned, the resident's goals, and a summary of medications with dietary instructions. When the surveyor requested the baseline care plan, the Nursing Home Administrator stated that nursing handles baseline care planning in their initial assessment but did not provide additional information by the time of the surveyor's exit.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. Resident #28 was identified as a smoker, with multiple smoking assessments and a smoking contract in place. However, the resident's care plan did not include any information related to smoking until after the surveyors' visit. The surveyors found cigarette butts and an empty cigarette pack in the resident's room, despite the resident denying smoking. Additionally, the resident was observed smoking without an oxygen tank, which was not addressed in the care plan. The Nursing Home Administrator confirmed the absence of a smoking care plan for Resident #28 during the surveyors' visit. Similarly, Resident #125, who had expressed a goal to be discharged to the community, did not have a care plan addressing discharge planning, despite being admitted to the facility in late January 2024. The Nursing Home Administrator acknowledged the lack of a discharge care plan for this resident during the interview with the surveyors. Resident #111's care plan indicated that the resident was independent with bathroom Activities of Daily Living (ADL), yet the staff were using incontinence briefs on the resident. The resident was not on a toileting program to address incontinence, which was inconsistent with the care plan. The Administrator acknowledged the discrepancy and expressed concern over the findings. These deficiencies highlight the facility's failure to develop and implement comprehensive care plans that address the specific needs of the residents, leading to inadequate care and oversight.
Failure to Cut Resident's Toenails
Penalty
Summary
The facility staff failed to ensure that a resident's toenails were cut. This was evident for one resident who had a long toenail on the big toe of the right foot, measuring about one inch above the toe. The resident reported that no one had cut the toenails even after the dressings on the feet were changed. The long toenail was observed again four days later, indicating that the issue had not been addressed. The Regional Clinical Director confirmed that the resident had a podiatry appointment the previous week.
Inadequate Activities Program for Residents
Penalty
Summary
The facility failed to have an activities program designed to meet the interests and needs of residents based on their comprehensive assessment and care plan. This deficiency was evident in two residents reviewed for activities during the survey. Resident #7, who has a medical history including paranoid schizophrenia, major depressive disorder, adjustment insomnia, and mild cognitive impairment, expressed preferences for group activities, keeping up with the news, going outside, participating in religious practices, and doing favorite activities. Despite these preferences, the care plans and documented activities did not align with Resident #7's expressed interests. Observations showed Resident #7 frequently lying in bed, and the activity logs indicated minimal engagement, primarily involving snack delivery and occasional light conversation, failing to meet the resident's stated needs for meaningful activities and social interaction. Similarly, Resident #79 reported that the facility's activities were limited to snacks, music, and conversation, which was corroborated by the activity logs. The logs showed minimal and repetitive activities such as coloring material drop-offs and supply deliveries being counted as activities. The Administrator and Regional Clinical Director acknowledged the lack of adequate activities when shown the documentation. This indicates a systemic issue in the facility's activities program, failing to provide residents with engaging and meaningful activities as per their preferences and care plans.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or less during a re-certification survey. During an observation of medication administration, a Certified Medication Aide (CMA) did not administer Vitamin D to a resident as ordered and incorrectly documented it as given. Additionally, the CMA administered Levothyroxine to another resident after breakfast, contrary to the order specifying it should be given before breakfast. The CMA confirmed these errors during an interview. The surveyor informed the Nursing Home Administrator (NHA) and Director of Nursing (DON) that the medication administration observation resulted in an error rate of 8%.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain a safe and effective system for securing medication and treatment carts on the nursing units. During a random tour of the 1st floor nursing station, a surveyor observed an unlocked medication cart containing medications labeled with residents' names and room numbers. The LPN responsible for the cart confirmed it was his responsibility and acknowledged that the facility's expectation was for the cart to be locked when unattended. Similarly, an unlocked treatment cart was observed on the 1st floor, containing various medical supplies. The LPN responsible for this cart also confirmed it should have been locked when unattended. On a subsequent tour of the 3rd floor nursing unit, another unlocked treatment cart was observed, containing medical supplies such as scissors, ointments, bandages, and dressings. The RN responsible for this cart confirmed it was his responsibility and that it should have been locked. Interviews with the NHA and DON revealed that the facility's expectation was for all medication and treatment carts to be locked when unattended. The NHA mentioned that an in-service had been conducted to address the issue of unlocked carts, but it was unclear how new and agency night shift employees were provided with this education.
Failure to Assist Resident in Obtaining Necessary Dental Care
Penalty
Summary
The facility staff failed to assist Resident #13 in making necessary appointments for dental care or treatment. During an observation and interview, the resident, who had only three teeth left and reported gum pain, revealed that no further dental appointments were made after a dentist recommended extractions during an on-site visit. The resident's medical record showed a history of tobacco use, bilateral above-knee amputations, dementia, and anxiety. Despite the dentist's recommendation for extractions during a visit on 4/3/23, no extractions were performed during subsequent visits on 6/23/23 and 7/5/23, and no further appointments were scheduled. The Administrator acknowledged the failure to assist the resident in obtaining the necessary dental care and treatments.
Failure to Employ Licensed Practical Nurse in Accordance with State Laws
Penalty
Summary
The facility failed to employ a Licensed Practical Nurse (LPN) in accordance with Maryland State laws. During a review of Staff #13's employee file, it was found that the LPN had an active Virginia Practical Nurse License but lacked necessary documentation such as education transcripts, hire application, evaluations, or disciplinary actions. The Nursing Home Administrator (NHA) confirmed that the LPN was hired while residing in Virginia but currently resides in Maryland, as indicated on her I-9 form. The NHA acknowledged awareness of the requirement for nurses to have an active license in the state of their primary residence and stated that Staff #13 has been informed to apply for a Maryland State Board of Nursing license.
Failure to Secure Bed Mattresses
Penalty
Summary
The facility failed to ensure that residents' bed mattresses were properly secured to the bed frames, leading to safety concerns. This deficiency was observed in two residents. Resident #97's mattress was repeatedly found slid over, exposing approximately 4 inches of the bed frame on multiple occasions. Despite the Maintenance Director's acknowledgment of the issue and a promise to inspect the bed, the problem persisted. Resident #97 had a history of falling and required supervision or assistance while moving in bed, as documented in the medical record and Minimum Data Set (MDS) assessment. The last bed inspection for Resident #97's room was completed in May 2023, indicating a lack of regular inspections. Similarly, Resident #85's mattress was observed slid down, exposing the top right corner of the bed frame. Resident #85, who had bilateral amputation and required assistance with transfers and moving in bed, reported using the bed frame to help move around. The Maintenance Director acknowledged the safety concern and promised to inspect the bed. The last bed inspection for Resident #85's room was also dated May 2023. The deficiency highlights the facility's failure to conduct regular and thorough inspections of bed frames and mattresses, leading to potential safety risks for the residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects in a resident's room. During a medication administration observation, multiple gnats were observed swarming inside the room. The Director of Nursing (DON) was called to the room and confirmed the infestation, noting that the privacy curtain was covered in gnats. The DON took pictures and reported the issue to the Nursing Home Administrator (NHA). The NHA was initially unaware of the infestation and stated she would investigate. A review of pest logs revealed that the facility had received extermination treatments for gnats.
Failure to Monitor and Document Required In-Service Training for Nurse Aide Staff
Penalty
Summary
The facility failed to monitor staff to ensure required in-service training for nurse aide staff was completed. This deficiency was identified during an employee record review and interviews, specifically for Geriatric Nursing Assistant (GNA) Staff #48. The surveyor noted that the employee file for Staff #48, who was hired on 10/16/2023, lacked documentation of required education. Despite the facility's use of Relias, a computer-based training program, and On Shift, a messaging system, there was no evidence that Staff #48 had completed the necessary in-service training. The staff educator, who had been in the position for two months, confirmed that it was her responsibility to track in-service and education for nursing staff but could not provide the required documentation for Staff #48. Further interviews with the Human Resources Director and the Corporate Human Resource Business Partner revealed that all completed education should be part of the employee's file. However, the only training documentation provided for Staff #48 included modules completed in 2019 and 2020, with only one training completed in 2024. The Nursing Home Administrator confirmed that Staff #48 had been hired in a different position in October 2023 and had previously worked in a different role in 2019. Despite efforts to locate additional education records, none were found, confirming the deficiency in monitoring and documenting required in-service training for nurse aide staff.
Failure to Inform Resident's Representative of Care Plan Changes
Penalty
Summary
The facility failed to honor the rights delegated to a resident's representative by not informing them of changes to the plan of care. Resident #77 was admitted in early August 2023 and was evaluated by two providers in September 2023, who had conflicting assessments regarding the resident's ability to appoint a healthcare representative. Despite the evaluations indicating the resident's incapacity to make informed decisions, the social history assessment completed in October 2023 incorrectly indicated that Resident #77 had decision-making capacity and did not list a healthcare proxy or agent. This discrepancy led to confusion about who should be contacted for decisions regarding the resident's care. Further review of Resident #77's medical records revealed multiple instances where changes in the resident's condition were documented, but the notifications were inconsistently made to either the resident or the ex-spouse, who was listed as an emergency contact. Interviews with staff indicated a lack of clarity and proper documentation regarding the resident's representative. The Nursing Home Administrator acknowledged the oversight and stated that a surrogate form should have been filled out to indicate the decision-maker for the resident, which was not done by the social services staff.
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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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