Forest Haven Nursing And Rehabilitation Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Catonsville, Maryland.
- Location
- 701 Edmondson Avenue, Catonsville, Maryland 21228
- CMS Provider Number
- 215252
- Inspections on file
- 18
- Latest survey
- September 15, 2025
- Citations (last 12 mo.)
- 54
Citation history
Health deficiencies cited at Forest Haven Nursing And Rehabilitation Ctr during CMS and state inspections, most recent first.
Staff failed to provide required two-person assistance during bed positioning for a resident with complex medical needs, resulting in a fall and fracture. Another resident was allowed to keep and self-administer multiple medications at the bedside, despite facility policy and concerns about unsafe use, after staff did not provide the requested medications.
The facility did not conduct initial or ongoing competency assessments for nurse aides, as evidenced by the lack of skills assessments in an aide's file and confirmed by the administrator and DON. Interviews revealed that there was no formal process or skills lab in place to verify staff competency, and competency evaluations were not routinely performed.
Administration did not conduct annual performance reviews or provide regular in-service education for nurse aides, as confirmed by file reviews and staff interviews during an investigation into staff-to-resident abuse. The DON acknowledged that no yearly evaluations had been performed for nursing staff since assuming her role.
Surveyors observed multiple failures in food storage and kitchen sanitation, including grease buildup, debris, unsealed food containers, dirty equipment, and inadequate cleaning schedules. The kitchen and storage areas were found with dirt, dust, food particles, and mice traps, with several areas not being cleaned as required by professional standards.
Staff failed to properly dispose of garbage and refuse, with observations including littered cigarette butts, broken furniture, unsecured gates, piles of debris, and open dumpsters with scattered trash and pallets.
Administration failed to ensure systems for staff performance evaluation and required education, with only one annual evaluation in seven years for a GNA and insufficient training on cognitive impairment. Policies and procedures were not accessible to direct care staff, with only one nursing manual available and confusion among staff about their location. The facility also did not maintain an effective pest control program, as evidenced by ongoing pest complaints, unsanitary conditions, and unaddressed recommendations from the pest control company.
The facility did not ensure that its QAA committee included the Medical Director and an Infection Preventionist, as required. Attendance records showed repeated absences of these key members from QAPI meetings, and there was a lack of documentation for some scheduled meetings. The current Infection Preventionist attended some meetings only as an MDS nurse, not in the required role.
Surveyors found that the facility failed to maintain a safe and homelike environment, with observations of dust-covered vents and heaters, damaged doors and walls, cracked flooring, and missing closet and bathroom doors in resident rooms. The sole maintenance staff member reported the absence of a preventative maintenance program and insufficient time to address cleaning and repairs.
The facility did not maintain an effective pest control program, resulting in ongoing infestations of mice and cockroaches throughout the building. Multiple complaints and observations confirmed pest activity in resident rooms, the kitchen, and common areas, with unsanitary conditions and structural issues contributing to the problem. Pest control recommendations for improved sanitation and building maintenance were not implemented, and communication lapses among staff further hindered effective pest management.
A surveyor observed that food delivered to a resident was not at appropriate temperatures, with hot items such as an egg omelet and sausage measuring below standard serving temperatures. The Certified Dietary Manager confirmed the findings after testing a tray from the meal cart, and the Administrator was notified of the issue.
Staff did not timely report an allegation of abuse involving a resident's claim of stolen marijuana, and documentation was lacking for the reporting of a resident-to-resident altercation that resulted in injury. Required notifications to the state agency and documentation of incident reporting were not completed as mandated.
Facility staff failed to properly investigate allegations of misappropriation of property and abuse involving three residents. In one case, a resident's report of stolen property was not formally investigated. In two other cases, allegations of staff-to-resident abuse were not thoroughly investigated, with incomplete documentation, lack of witness statements, and failure to remove the accused staff from resident contact during the investigation.
Facility staff did not create or implement comprehensive, person-centered care plans for two residents, resulting in unmet needs related to medical appointments and management of a recurrent rash. One resident's care plan failed to address their preferences and behaviors regarding outside medical consults, while another resident's care plan did not provide specific approaches for a persistent skin condition, despite repeated specialist involvement and ongoing symptoms.
A resident with severe cognitive impairment and documented preferences for specific activities did not receive an individualized activities program. The care plan was not tailored to the resident's needs, lacked measurable goals, and there was minimal documentation of activity participation or one-to-one engagement by staff. Observations and records showed the resident was not regularly involved in activities, and staff interviews confirmed gaps in documentation and care planning.
A resident with a recurrent leg rash and multiple chronic conditions did not have a cancelled dermatology appointment rescheduled as ordered by the physician. The lapse occurred due to a lack of communication between nursing and the staff responsible for scheduling, resulting in the resident not receiving timely follow-up care for the ongoing rash.
Staff did not follow physician orders or develop individualized interventions for a resident at risk for pressure ulcers, including missing required Braden Scale assessments and failing to specify or document turning, repositioning, and use of prescribed treatments. The resident subsequently developed a sacral wound, and documentation of preventive care remained inconsistent even after new interventions were ordered.
A resident with dementia and behavioral disturbances received a PRN order for Lorazepam that was not limited to 14 days and lacked a documented rationale for continuation beyond this period. The medication was administered without evidence that non-pharmacological interventions were attempted first, and required documentation was missing.
A resident was found with several medications, including medicated spray, topical cream, and various liquid medications, left unsecured on an over-the-bed table. The resident reported keeping these medications at the bedside due to staff refusal to retrieve them, and that a family member had supplied the medications. The DON confirmed the medications were not properly stored and had not been reported by staff. The attending physician was aware of the situation but proper storage was not maintained.
The facility did not conduct or document a comprehensive facility-wide assessment, resulting in missing and outdated information about resident census, staff levels, and resource needs. The assessment lacked a full evaluation of resident diagnoses, acuity, and care requirements, and did not address staff competencies, facility resources, or contracted services. The Nursing Home Administrator acknowledged these deficiencies during the survey.
Surveyors identified that the facility did not maintain an accurate inventory of a resident's personal belongings, including high-value items and their disposition after discharge, and failed to ensure consistent and complete documentation of end-of-life choices for another resident. Conflicting information was found between the EMR, paper records, and care plans regarding code status, and two active MOLST forms with different directives were present in the medical record.
A resident with a history of sexually inappropriate behavior was involved in multiple incidents of abuse and misappropriation of property. Despite being witnessed by staff, the facility failed to investigate or report these incidents to the State agency. The resident's behavior care plan noted various problematic behaviors, which were not adequately addressed, leading to further occurrences of abuse involving vulnerable residents.
A facility failed to implement abuse prevention policies by not notifying the administrator or state agency of abuse allegations involving a resident with dementia and a history of inappropriate behavior. The resident was involved in multiple incidents, including inappropriate sexual behavior and misappropriation of another resident's property, yet no investigations or reports were made.
A resident with dementia and other conditions was involved in multiple incidents of alleged abuse, including inappropriate contact and theft, affecting two other residents. Despite these events, the facility did not investigate or report the allegations to the State agency, as confirmed by the DON.
A resident was sent to the ER due to inappropriate behavior and was cleared for return, but the facility refused readmission without proper documentation or communication. The facility failed to issue a 30-day notice or inform the resident's representative and the State Ombudsman. Interviews revealed a lack of communication among staff and medical personnel regarding the resident's situation.
A facility failed to notify a resident, their representative, and the State Ombudsman about the resident's transfer to the hospital and subsequent refusal to readmit them. The resident was sent to the emergency room after inappropriate behavior with another resident. The facility did not issue a 30-day discharge notice or provide written correspondence, citing the absence of administrative staff during weekends.
A resident was sent to the ER due to inappropriate behavior and was cleared for return, but the facility refused re-admittance without issuing a 30-day notice or notifying the resident's representative. The facility cited safety concerns but failed to communicate properly, leading to a deficiency.
A facility failed to provide a bed hold policy to a resident transferred to the ER after inappropriate behavior. The resident was cleared for return but was not allowed back. The administrator admitted no notice or correspondence was sent to the resident's representative or Ombudsman, and the medical record lacked the bed hold policy.
A resident was not permitted to return to the facility after a brief hospitalization due to concerns about safety following inappropriate behavior. The facility did not issue a 30-day involuntary notice or inform the resident's representative or the State Ombudsman. Additionally, the resident was not provided with the bed hold policy, and the representative was unaware of the facility's refusal to re-admit the resident.
Failure to Provide Adequate Supervision and Safe Medication Management
Penalty
Summary
Facility staff failed to provide adequate supervision and safe care during activities of daily living for a resident with significant medical needs, including respiratory failure, heart failure, a vertebral fracture, hospice care, and dementia. The resident required extensive assistance from two staff members for repositioning in bed, as documented in the MDS assessment. However, a Geriatric Nursing Assistant provided care alone and left the resident unattended on her side in bed to retrieve supplies. During this absence, the resident fell from the bed and sustained a fracture to the left superior pubic ramus. The incident was confirmed by facility records and staff interviews, and the administrator acknowledged that staff did not follow the facility's ADL policy for supervision. Additionally, another resident was found to have multiple medications, including medicated spray, Desitin, Pepto Bismol, and cough syrup, stored openly at the bedside. The resident reported keeping these medications because staff would not provide them, and a family member supplied them. Facility policy prohibits residents from having medications at the bedside, and the DON was unaware of the situation until it was observed. Social Services staff and the attending physician confirmed that the resident had a history of keeping medications in the room and that self-administration was considered unsafe due to concerns about overuse. Despite these concerns, staff continued to allow the resident to keep and self-administer the medications.
Failure to Ensure Staff Competency Assessments
Penalty
Summary
Facility staff failed to ensure that nurse aides demonstrated competency in the skills and techniques necessary to care for residents' needs. During the investigation of an abuse allegation involving a resident, a review of a Geriatric Nursing Assistant's (GNA) employee file revealed that, although a general orientation checklist was present, there was no evidence of initial or ongoing skills assessments to confirm competency. The administrator confirmed that no such skills assessments existed for this staff member. Interviews with the Director of Nursing (DON) and the Human Resources director further revealed that the facility did not have a formal process for evaluating staff skills competency. The DON, who had recently assumed the position, stated that there was no formal method in place for verifying nurse and GNA competencies, and that the facility did not have a skills lab. The DON also indicated that, aside from pharmacy-conducted medication pass observations for nurses, no formal competency evaluations were conducted.
Failure to Complete Annual Performance Reviews and In-Service Education for Nurse Aides
Penalty
Summary
The facility administration failed to complete annual performance reviews for every nurse aide and did not provide regular in-service education based on the outcomes of such reviews. During the investigation of an allegation of staff-to-resident abuse, it was found that a Geriatric Nursing Assistant (GNA) had only one annual performance evaluation on file since being hired, with no subsequent yearly evaluations available. The Director of Nursing (DON) confirmed that annual performance evaluations for nursing staff had not been conducted since she assumed her position, and the Human Resources director corroborated this information. These findings were based on employee file reviews and staff interviews.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
Facility staff failed to store, prepare, and serve food in accordance with professional standards of food service safety, as evidenced by multiple observations during two separate kitchen tours. Surveyors found grease layered on tiles, debris such as paper and plastic under and behind kitchen items, dust and dirt on floors, and mouse traps set throughout the kitchen. The prep supply area was dirty, insulation was coming off pipes under the sink, and food items like bread and elbow noodles were found on carts and the floor. An open bag of flour was left unsealed, and the clean food cart storage area had water-stained ceiling tiles, dirty floors, a large hole in the wall, and missing floor tiles. The cleaning schedule provided by the Dietary Manager did not include the dry storage area or specify that all floors should be mopped and trash cleaned up. Further observations included dirty mouse traps with food particles, sticky floors, vents and pipes with grease and dust buildup, and a refrigerator with a damaged seal. The bulletin board and air conditioning unit were dirty, and rolls of foil and plastic wrap were stored inappropriately. The stove, mixer, and meat slicer were left uncovered or uncleaned, and open containers of sugar were not properly sealed. Food carts, the fire suppression system, and the metal connection box had accumulations of dirt, food crumbs, and mice droppings. Hand sinks were blocked or dirty, and the hand sanitizer dispenser was unclean. The Administrator was made aware of these findings and had no additional comments.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Facility staff failed to properly dispose of garbage and refuse, as observed during tours of the smoking and dumpster areas. Specific findings included cigarette butts littering the ground, broken pallets and chairs placed next to the building, unsecured gates that could be opened by residents, and piles of plywood, broken air conditioners, buckets, and trash in various locations. Additional observations included food serving carts in disrepair, a commercial hair drying unit leaning on metal doors, multiple air conditioners and food carts stored in the yard, ladders against the wall, an open shed filled with debris, and various pieces of trash and old furniture scattered around. In the dumpster area, dumpsters were found with open side doors, a pile of pallets, and milk containers scattered around, all contributing to improper refuse disposal.
Deficiencies in Staff Evaluation, Policy Accessibility, and Pest Control
Penalty
Summary
Facility administration failed to establish and ensure systems for evaluating staff performance and providing required education based on performance reviews and facility assessment. Review of an employee file for a GNA revealed only one annual performance evaluation over seven years of employment, and insufficient annual training on cognitive impairment and mental illness. Interviews with the DON and HR Director confirmed that annual performance evaluations were not conducted for nursing staff, and there was no formal process for ongoing competency verification or structured training needs assessment. Staff interviews indicated that policies and procedures were not readily available or accessible to all staff. Multiple staff members believed that policy binders were located in the nurse's station, but upon inspection, only a wound care policy binder was found. Other staff referenced policies being kept in various locations or with department heads, but the DON confirmed that direct care staff did not have access to policies and procedures on the units, and only one nursing manual was available in the facility. The facility also lacked an effective pest control program. Complaints and observations revealed ongoing issues with mice and cockroaches, unsanitary kitchen conditions, and structural deficiencies such as gaps and holes allowing pest entry. Pest control company recommendations for maintaining sanitation and building repairs were not implemented, and documentation showed only monthly pest control visits despite claims of increased frequency. Maintenance staff were not receiving pest control reports, and structural recommendations were not followed up, contributing to persistent pest issues.
Failure to Maintain Required QAA Committee Membership and Meeting Attendance
Penalty
Summary
Facility staff failed to maintain a Quality Assessment and Assurance (QAA) committee that included the required members, specifically the Medical Director and an Infection Preventionist. Review of QAPI (Quality Assurance Performance Improvement) committee meeting attendance sheets from April 2024 through April 2025 revealed that the Infection Preventionist was absent from multiple meetings, including several quarterly meetings, and the Medical Director was also absent from several meetings. Additionally, there was no evidence that meetings were held in certain months, as no sign-in sheets or documentation were available for those periods. Further review indicated that although the current Infection Preventionist had recently assumed the role, neither the current nor former Infection Preventionists attended the required meetings in that capacity. The staff member who is now the Infection Preventionist was present at some meetings, but only in the role of an MDS nurse, not as the Infection Preventionist. The absence of these key committee members was confirmed through record review and staff interviews.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe and homelike environment for residents. On the second floor, hallway heaters and vents were found covered with dust, and in one resident's room, the bathroom door had scuff marks and peeling veneer near the doorknob. The sink in the same room was dripping water, the flooring was cracked in two places, and the wall outside the bathroom was damaged and unpainted. The heating vent under the sink was also caked with dust. In another room, there were gaps where pipes entered the wall, and the vent under the window, as well as hallway vents, were heavily dust-laden. Additionally, one resident's room was missing doors on both the closet and bathroom. During an interview, the Maintenance Assistant stated that the facility did not have a preventative maintenance program to ensure resident rooms were maintained in a safe and homelike manner. He indicated that maintenance was only performed when issues were reported by nursing staff and that he was the sole maintenance worker since February, which prevented him from keeping up with cleaning and repairs. The new Maintenance Director later acknowledged these concerns.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in ongoing issues with mice, cockroaches, and other pests throughout the building. Multiple complaints were received regarding mice infestations, rodent droppings in resident rooms and the kitchen, and sightings of pests by visitors and residents. Observations confirmed the presence of pests and pest evidence in various areas, including a large hole in a wall near food storage, cockroaches in resident rooms and bathrooms, and mouse traps placed in response to sightings. The kitchen was found to be unsanitary, with layers of grease and dirt, and pest control recommendations for improved sanitation and building maintenance were not implemented. Outdoor areas, such as the resident smoking area and dumpster area, were cluttered with debris and had open containers, further contributing to pest problems. A review of the pest control policy revealed missing implementation details and lack of a designated pest management coordinator. Pest control logs showed regular pest sightings, and receipts from the pest control company documented ongoing recommendations for structural repairs and increased sanitation, which were not followed. Interviews with maintenance staff indicated a lack of communication and follow-up on pest control reports and recommendations. The administrator reported treating areas based on pest logs and claimed to increase pest control visits when needed, but documentation did not support this. The facility's failure to address structural issues, maintain cleanliness, and implement pest control recommendations led to persistent pest infestations affecting the entire facility.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. During a lunch tray line observation, a surveyor and the Certified Dietary Manager (CDM) monitored the process of food delivery, including the use of a test tray. The food cart was parked in a hallway while nursing staff distributed trays to residents' rooms. When the CDM measured the temperatures of the test tray items, the egg omelet with cheese registered at 98°F, sausage at 90°F, and milk at 42°F. The CDM confirmed these temperatures, which did not meet the required standards for hot food service. The Administrator was informed of the food temperature concern.
Failure to Timely Report Allegations of Abuse and Resident-to-Resident Altercation
Penalty
Summary
Facility staff failed to report an allegation of abuse in a timely manner to the State Agency. In one instance, a resident became agitated and accused staff of stealing marijuana, which is not permitted in the facility. The nurse documented the resident's allegation in the medical record, the 24-hour report, and verbally reported it to the oncoming nurse and the nursing supervisor. However, the allegation was not reported to administration or the State Agency, and the Clinical Services Director later confirmed that the incident was not reported as required. In a separate incident, one resident struck another on the head with a cane, resulting in a laceration. The facility's investigation did not include documentation of when the incident was reported to the Office of Health Care Quality (OHCQ) or when the final report was sent. The Nursing Home Administrator was unable to provide documentation of the reporting, as email confirmations had been deleted and were unavailable for review by the surveyor.
Failure to Investigate Allegations of Abuse and Misappropriation
Penalty
Summary
Facility staff failed to investigate an allegation of misappropriation of property for one resident who reported that their marijuana was stolen. The resident, who had previously expressed frustration about not being allowed to use marijuana for pain management, reported the alleged theft to nursing staff, who documented the complaint in the medical record and 24-hour report, and informed the oncoming nurse and supervisor. However, no formal investigation was conducted by administration or clinical leadership after the allegation was made. In a separate incident, the facility did not conduct a thorough investigation into an allegation that a Geriatric Nursing Assistant (GNA) threw cookies at a resident, striking them on the nose. The facility's documentation lacked statements from staff or residents regarding the alleged event, and the GNA in question was not removed from resident contact during the investigation period, despite working multiple shifts on the unit where the resident resided. The investigation relied on limited and, in one case, outdated staff statements, and did not include comprehensive interviews or evidence collection. Additionally, the facility failed to conduct a complete investigation into an allegation of abuse involving another resident with a mental health disorder and dementia. The investigation file did not contain a statement from the resident or from all potential witnesses, and although the accused GNA denied contact with the resident, there was no further inquiry into their assignment or possible interaction. The DON and Administrator acknowledged that an interview with the resident had occurred but could not provide documentation of it, and the investigation file was incomplete.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet needs related to medical appointments and skin care. For one resident, the medical record showed multiple physician orders for dental, cardiology, neurosurgery, and neurology consults, but there was no evidence that these appointments were attended. The resident often scheduled and canceled appointments independently, and staff did not maintain documentation of when or where the resident went for these appointments. Interviews with the Administrator and Transportation/Scheduler confirmed that the facility was not consistently involved in arranging or tracking the resident's outside medical visits, and the care plan did not address the resident's preferences or behaviors regarding appointment scheduling and attendance. Another resident experienced a recurrent rash on the lower legs, with documentation of ongoing symptoms and repeated courses of topical treatment. The resident was seen by both dermatology and rheumatology, and follow-up appointments were ordered, but the care plan addressing skin integrity was generic and not tailored to the resident's persistent and recurring condition. The care plan lacked specific, measurable actions or approaches to address the ongoing rash, despite repeated documentation of the issue and multiple specialist referrals. In both cases, the facility's care planning process did not adequately address the residents' individual needs, preferences, or the complexity of their medical situations. The deficiencies were identified through medical record review and staff interviews, which revealed gaps in documentation, lack of comprehensive planning, and insufficient coordination of care for residents with ongoing or complex health concerns.
Failure to Provide Resident-Centered Activities Program
Penalty
Summary
Facility staff failed to provide an activities program that met the needs and preferences of a resident with severe cognitive impairment. The resident, who had a diagnosis of dementia with behavioral disturbance and a BIMS score indicating severe cognitive impairment, had documented preferences for activities such as reading, listening to music, being around animals, keeping up with the news, participating in group activities, going outside, and engaging in religious practices. Despite these documented preferences, the care plan for activities was not individualized and lacked measurable goals and specific approaches tailored to the resident's needs. Observations during the survey revealed that the resident was either in their room or ambulating in the hallway and was never observed participating in any activities or receiving one-to-one engagement from staff. Review of activity participation logs showed that activities were only provided on a few days each month, with no documentation of daily or individualized activities, and no records of participation for two consecutive months. The care plan inaccurately stated that the resident was independent in meeting their activity needs, despite evidence of cognitive impairment and the need for staff engagement. Interviews with the Activity Director confirmed that one-to-one visits and group activity invitations were supposed to be documented, but there was a lack of documentation to support that these interventions occurred regularly. The absence of a resident-centered care plan and insufficient documentation of activity participation led to the finding that the facility did not meet regulatory requirements for providing an activities program that addresses the unique needs and preferences of the resident.
Failure to Reschedule Dermatology Appointment as Ordered
Penalty
Summary
Facility staff failed to follow physician orders for a resident who had a recurrent rash on the lower legs. The resident, who had diagnoses including dementia, hypertension, and hypothyroidism, had been prescribed the same ointment multiple times and was under the care of both rheumatology and dermatology for the rash. Medical records showed that the resident was seen by rheumatology and dermatology as ordered, but a dermatology appointment scheduled for February was cancelled due to an elevator malfunction at the hospital. Although there was a physician order to reschedule the dermatology appointment, there was no documentation that the follow-up appointment was ever scheduled. Interviews revealed that the staff member responsible for scheduling appointments and transportation was not notified by nursing to reschedule the dermatology appointment. The attending physician confirmed that the expectation was for the appointment to be rescheduled if missed, and was unaware that it had not been done. The deficiency was identified when it was found that the resident continued to have a rash and lacked current treatment or follow-up with dermatology as ordered.
Failure to Implement and Document Individualized Pressure Ulcer Prevention Measures
Penalty
Summary
Facility staff failed to implement appropriate individualized interventions for a resident identified as at risk for developing pressure ulcers. Upon admission, the resident was noted to have redness to the groin and buttock, but the documentation did not specify the size or whether the redness was blanchable. Physician orders included daily and weekly skin checks, weekly Braden Scale assessments for four weeks, and application of a moisture barrier cream. However, staff did not complete the required weekly Braden Scale assessments as ordered, and the interim plan of care did not specify individualized interventions to address the resident's skin integrity risk. The comprehensive care plan also lacked specific measures for turning and repositioning, use of prescribed moisture barrier cream, and the pressure-reducing device, despite the resident's dependence on staff for mobility and hygiene. The resident later developed an open area on the sacrum, which was first identified as unstageable, prompting new interventions such as an alternating pressure mattress, urinary catheter, and scheduled turning and repositioning. Documentation revealed that staff did not consistently record turning and repositioning assistance both before and after these interventions were added to the care plan. Interviews with the attending physician and DON confirmed that appropriate interventions were not in place or documented prior to the development of the pressure ulcer, and that staff failed to follow physician orders and facility protocols for residents at risk of pressure ulcers.
Failure to Limit and Document PRN Psychotropic Medication Orders
Penalty
Summary
Facility staff failed to ensure compliance with regulations regarding the use of as needed (PRN) psychotropic medications for a resident with dementia and behavioral disturbances. A physician order for Lorazepam, to be administered prior to blood draws, was written as a PRN order without a 14-day limitation or a specified duration and discontinuation date. The medical record did not contain documentation from the physician providing a rationale for continuing the PRN order beyond 14 days, as required by regulation. Additionally, review of the medication administration record showed that Lorazepam was administered to the resident, but there was no documentation indicating that non-pharmacological interventions were attempted prior to giving the medication. These findings were confirmed during interviews with the Director of Nursing and the Nursing Home Administrator, who acknowledged the lack of appropriate documentation and understanding of the requirements for PRN psychotropic medication orders.
Medications Improperly Stored at Bedside
Penalty
Summary
Facility staff failed to ensure that all medications and biologicals were stored in locked, temperature-controlled compartments as required. During an observation, a resident was found with multiple medications, including medicated spray, Desitin, Pepto Bismol, liquid pectate, severe congestion liquid medication, and cough syrup, left out in the open on the over-the-bed table in the resident's room. The resident stated that these medications were kept at the bedside because staff refused to retrieve them, and that a family member had purchased and brought the medications to the facility. The DON confirmed the presence of these medications during a follow-up observation and noted that staff had not reported this situation. The attending physician was aware of the medications at the bedside and had discussed the issue with the resident and administration multiple times, but proper storage was not ensured. These findings were reviewed with the Nursing Home Administrator and Clinical Services Director.
Failure to Conduct and Document Comprehensive Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive and accurate facility-wide assessment to determine the resources necessary to care for residents competently during both routine operations and emergencies. During a complaint survey, the facility provided a binder labeled as the facility assessment, but review of its contents revealed significant omissions and outdated information. The facility profile lacked current data, such as the average resident census and accurate staff information, and did not include the average number of staff on nights. Additionally, the profile listed contact information for previous administrators and maintenance directors, indicating it was not up to date. Further review showed that the assessment did not adequately evaluate the resident population's needs, including an analysis of diseases, conditions, physical and cognitive abilities, and overall acuity. The comorbidity report was limited to 50 residents and did not provide a comprehensive assessment of the entire population. The assessment also failed to address the specific care requirements for residents, such as the types of diseases and disabilities present, and did not evaluate the staff competencies necessary to meet these needs. There was no documentation of staff education, training, or health information technology resources relevant to the resident population. The facility assessment was also missing evaluations of the facility's physical resources, such as buildings, vehicles, equipment, and contracted services. There was no evidence of an assessment of ethnic, cultural, or religious factors that could affect care, nor was there documentation of an evaluation of the number of staff required to meet resident needs. The list of contracted providers did not include an evaluation of how these services would meet regulatory, operational, or training requirements. These deficiencies were acknowledged by the Nursing Home Administrator during the survey.
Failure to Maintain Accurate Resident Property Inventory and End-of-Life Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete inventory of a resident's personal belongings, as well as failed to document the disposition of those belongings upon the resident's discharge. One resident's medical record did not contain an inventory of personal items, including a motorized wheelchair and marijuana, despite staff acknowledging the presence and storage of these items. There was no documentation regarding the final disposition of these belongings after the resident was transferred to the hospital, and the facility was unable to provide a policy specific to the inventory of residents' belongings beyond a general admission policy. Additionally, the facility did not ensure accurate and complete documentation of residents' end-of-life choices. For another resident, the electronic medical record (EMR) indicated a code status of 'Full Code,' while the paper record contained an active MOLST form indicating 'Do Not Resuscitate/Do Not Intubate' (DNR/DNI) status. Staff interviews revealed reliance on both the EMR and paper chart for code status, but discrepancies existed between the two sources. The resident's care plan and a nurse practitioner's note also contained conflicting information regarding code status, and two active MOLST forms with different directives were found in the medical record. These deficiencies were evident during a complaint survey and were confirmed through record review, staff interviews, and observation. The lack of a consistent process for documenting and updating both personal property inventories and end-of-life directives led to incomplete and conflicting records for the residents involved.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident with a history of sexually inappropriate behavior. This resident, diagnosed with dementia and other mental health issues, was involved in several incidents of sexual abuse and misappropriation of property. On one occasion, the resident was found inappropriately touching another resident, who was unable to consent due to their condition. Despite the severity of these incidents, the facility did not conduct investigations or notify the State agency as required. The resident's behavior care plan noted various problematic behaviors, including sexual inappropriateness, which were not adequately addressed by the facility. The resident was observed engaging in inappropriate sexual conduct with multiple residents, including a bed-bound and demented resident, and another resident who was quadriplegic and dependent on staff for care. These incidents were witnessed by staff members, yet the facility failed to take appropriate action to prevent further occurrences or to report the incidents to the appropriate authorities. Additionally, the facility did not investigate or report an incident where the resident took personal items from another resident, causing distress. The lack of timely and appropriate response to these incidents highlights a significant deficiency in the facility's ability to protect residents from abuse and to comply with regulatory requirements for reporting and investigating allegations of abuse.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement abuse prevention policies, as evidenced by the staff's failure to immediately notify the facility administrator of allegations of resident abuse, sexual abuse, and misappropriation of resident property. This was evident in the cases of two residents during a complaint survey. Resident #1, who had a history of dementia and sexually inappropriate behavior, was found by a staff member in a compromising situation with another resident. Despite the incident being reported to a nurse and the physician being notified, the facility did not investigate or report the incident to the State Regulatory Agency. Additionally, Resident #1 was later observed attempting to touch female residents inappropriately, yet no investigation or notification to the state agency was conducted. Furthermore, Resident #1 was involved in an incident where personal items belonging to another resident, Resident #3, were taken, causing distress to Resident #3, who is quadriplegic and dependent on nursing staff. Despite the facility administrator being informed, no investigation or state agency notification occurred. Resident #1 was also observed engaging in further inappropriate behavior towards Resident #3, yet the facility again failed to investigate or report the incident. These failures highlight a significant deficiency in the facility's adherence to abuse prevention policies and reporting requirements.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to initiate investigations into multiple reported allegations of abuse involving two residents. Resident #1, who has a history of dementia, mood disturbance, psychotic disturbance, and bipolar disease, was involved in several incidents. On one occasion, Resident #1 was found in a compromising situation with another resident, Resident #4, which was reported by a staff member but not investigated or reported to the State agency. Additionally, Resident #1 was observed attempting inappropriate physical contact with female residents in the hallways, yet this incident also went uninvestigated and unreported. Furthermore, Resident #1 was involved in an incident where personal items belonging to Resident #3, who is quadriplegic and dependent on nursing staff, were taken, causing distress to Resident #3. Later, Resident #1 was observed hitting Resident #3. Despite these occurrences, the facility did not conduct investigations, obtain witness statements, or notify the State agency about these allegations of abuse. The Director of Nursing confirmed the lack of action during an interview.
Failure to Document and Communicate Resident Transfer
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding the transfer or discharge of a resident, as evidenced by the case of Resident #1. Resident #1 was sent to the emergency room under an emergency petition after being witnessed engaging in inappropriate sexual behavior with another resident. Despite being cleared for discharge back to the nursing facility, the facility refused to accept Resident #1's return, citing concerns for the safety of female residents. However, the facility did not issue a 30-day involuntary notice, nor did it provide written correspondence to the resident's representative or the local State Ombudsman's office. Additionally, no documentation was sent with the resident to the hospital. Interviews with facility staff and medical personnel revealed a lack of communication and coordination regarding Resident #1's situation. The Director of Nursing (DON) admitted that the facility was aware of Resident #1's behaviors for over a year but did not take appropriate steps to address the issue. The covering physician and the on-call nurse practitioner were not adequately informed or involved in the decision-making process. Furthermore, Resident #1's representative was not notified about the facility's refusal to readmit the resident, leaving them unaware of the resident's status. The facility medical director was also not involved in discussions about the decision to deny Resident #1's return.
Failure to Notify Resident and Representative of Transfer and Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the local State Ombudsman about the resident's transfer to the hospital and the subsequent refusal to readmit the resident. This deficiency was identified during a complaint survey involving a resident who was sent to the emergency room after being observed engaging in inappropriate sexual behavior with another resident. The facility did not issue a 30-day involuntary discharge notice or provide any written correspondence regarding the transfer or discharge to the relevant parties. The facility's Director of Nursing and administrator acknowledged that no notifications were made, citing the absence of administrative staff during weekends as a reason for the oversight. The resident's covering physician and representative were also not informed about the resident's status or the facility's decision not to readmit them. The facility medical director was not involved in the decision-making process regarding the resident's return, despite being aware of the incidents involving the resident and another resident who was a victim of the inappropriate behavior.
Failure to Ensure Safe and Orderly Resident Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge for a resident, leading to a deficiency identified during a complaint survey. The issue arose when a resident, who had been involved in inappropriate sexual behavior with another resident, was sent to the emergency room under an emergency petition. Despite being cleared for discharge back to the nursing facility, the facility refused to accept the resident's return, citing concerns for the safety of female residents. This decision was made without issuing a 30-day involuntary discharge notice or notifying the resident's representative or the local State Ombudsman's office. The facility's actions were further complicated by the lack of administrative staff present during the weekend when the incident occurred. The facility administrator admitted that no written correspondence was sent to the resident's representative or included with the resident when they were sent to the hospital. The resident's representative was not informed that the resident would not be accepted back into the facility, nor were they made aware that the resident was no longer residing there. This lack of communication and failure to follow proper discharge procedures contributed to the deficiency identified in the survey.
Failure to Provide Bed Hold Policy During Resident Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident when they were transferred to the emergency room. This deficiency was identified during a complaint survey involving a resident who was sent to the emergency room under an emergency petition after being observed for the second time in a 10-day period engaging in inappropriate behavior with another resident. The resident was evaluated and cleared for discharge back to the nursing facility, but the facility refused to allow the resident to return. During an interview, the facility administrator admitted that no 30-day involuntary notice or written correspondence was sent to the resident's representative or the local State Ombudsman's office, nor was it sent with the resident to the hospital. Additionally, the resident's medical record did not contain a copy of the facility bed hold policy upon their transfer to the hospital.
Facility Fails to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a brief hospitalization, which was identified during a complaint survey. The resident was sent to the emergency room under an emergency petition after being observed for the second time in a 10-day period engaging in inappropriate sexual behavior with another resident. The resident was evaluated and cleared for discharge back to the nursing facility, but the facility refused to accept the resident back, citing concerns for the safety of female residents. The facility did not issue a 30-day involuntary notice, nor did they send any written correspondence to the resident's representative or the local State Ombudsman's office. Additionally, the resident was not provided with a copy of the facility's bed hold policy upon being sent to the hospital. The resident's representative was not informed that the facility would not accept the resident back, nor were they made aware that the resident was no longer residing at the facility.
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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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