Frederick Crossing Of Journey
Inspection history, citations, penalties and survey trends for this long-term care facility in Frederick, Maryland.
- Location
- 30 North Place, Frederick, Maryland 21701
- CMS Provider Number
- 215184
- Inspections on file
- 22
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at Frederick Crossing Of Journey during CMS and state inspections, most recent first.
Failure to Maintain Resident Dignity During Personal Care, Feeding, and Room Entry: A resident with severely impaired cognition was observed with food-soiled clothing, food residue on the lips, and unshaved facial hair, while another resident with Parkinson's disease was fed by a GNA standing over the bed with no chair present. In separate incidents, a GNA entered a room without knocking or identifying himself and removed meal trays, and a phlebotomist entered another resident's room and began preparing to draw blood without first knocking, asking permission, or introducing herself.
Advance directive information was not provided to a resident who was documented as able to understand and make decisions. Social services requested a copy of the advance directive after admission, but the record had no copy and no documentation of follow-up or that the resident was given information to formulate one while still capable. Staff later noted the resident no longer had capacity and the POA on file was financial only, not for healthcare preferences.
A resident discharged from skilled care received a NOMNC showing the last covered Part A day, but no ABN was provided even though benefit days were not exhausted. The NHA and BOM confirmed that an ABN should have been given and that there was no evidence it had been provided.
The facility failed to complete Significant Change in Status MDS assessments within the required timeframe for two residents after hospice admission. One resident had a general decline and the other was admitted for failure to thrive; in both cases, the MDS coordinator confirmed the hospice admission date was the determination date, and both assessments were completed late.
A resident with a PASRR Level II positive result due to developmental delay had an MDS assessment that incorrectly marked “no” for the A1500 PASRR question. The social service designee confirmed the resident’s PASRR II status and acknowledged the MDS was recorded in error.
A resident with dementia and behavioral issues was observed taking food from other residents’ trays during lunch on the memory care unit. Records and staff interviews showed the resident was sometimes agitated, screamed at staff and other residents, was difficult to redirect, and had a usual behavior of grabbing other residents’ food, but these behaviors were not addressed in the care plan or linked to staff interventions.
Failure to hold and document care plan meetings after comprehensive assessments for two cognitively intact residents. One resident had recent annual and significant change assessments with no progress note documentation of care plan conferences, while the other had an annual and quarterly assessment, a scheduled meeting note, and a later verbal report that the IDT care plan conference occurred but was not documented in the chart.
A resident who was totally dependent on staff for showers did not receive the scheduled ADL assistance. The resident reported only one shower in 3 weeks, and record review showed only 3 showers over the reviewed period despite a schedule for 2 showers per week plus bed baths on non-shower days. Staff confirmed the missed showers, and no additional documentation was provided by survey exit showing the resident received all scheduled showers.
Failure to provide activities based on a resident’s needs and preferences. A resident with dementia and severely impaired cognition was repeatedly observed sitting alone and sleeping in a wheelchair with no activity program in progress. The care plan listed preferences for table activities, old sitcoms, bingo, and music, but activity logs did not show TV/sitcom participation, and staff confirmed the resident liked watching TV while the TV had been moved and was not working for months.
Inaccurate pressure-relieving mattress settings were found for three residents with pressure injuries. Each resident had an order for the mattress to be set within 10 lbs of current weight, but the observed settings were far above the documented weights. Staff gave differing responses about who was responsible for setting and checking the equipment, and the wound nurse confirmed the settings were not accurate.
Oxygen Therapy Given Above Ordered Rate: A resident with acute respiratory failure with hypoxia was observed receiving O2 via nasal cannula at rates higher than the ordered 2 L/min, including 3.5 L/min and later 7 L/min. The RN stated the O2 use fluctuated and could be titrated for panic attacks, but the chart had no order allowing titration and no documentation supporting the reported low O2 sat episode.
Pain Management Documentation Deficiencies: Two residents with orders for PRN pain meds and NPI documentation had incomplete pain management records. One resident’s PRN narcotic doses lacked pain location documentation and did not show NPI use before administration, while another resident received PRN pain medication twice despite a 0/10 pain score, with no documentation of NPI attempts before dosing.
A resident with dementia and behavior issues was observed grabbing bread and cake from two other residents’ meal trays during lunch, prompting one resident to yell and take the cake back. Records showed the resident was sometimes agitated, screamed at staff and other residents, and was difficult to redirect. Staff confirmed the resident’s usual behavior included taking other residents’ food, and the unit manager said a prior seating arrangement had not worked.
A resident medication cart on the 2 North unit was left unlocked and unattended while an LPN was inside a resident's room with the door shut. The surveyor was able to open and access the medication drawers, and the LPN acknowledged the cart had been left unsecured. This was identified during observation of 1 of 3 medication carts.
Failure to Assess and Record Food Preferences: A resident with recent significant wt loss and a nutrition care plan to honor food preferences repeatedly reported receiving eggs despite telling staff multiple times that eggs were disliked. The dietary profile listed the diet order and food texture, but the preferences/dislikes sections were left blank, and staff confirmed the assessment and entry process was missed for the resident.
Improper arbitration agreement consent was documented for a resident who lacked decision-making capacity and had no POA, guardian, or surrogate identified. The admissions staff member later confirmed she signed the resident's name on the agreement after discussing the admission packet with a family member and the resident as much as possible, and the NHA acknowledged the form was completed incorrectly.
Failure to use required PPE for EBP: A hospice aide provided high-contact care to a resident on EBP for wounds while wearing gloves but no gown. The resident was receiving hospice care, and the EBP sign on the door indicated gown and gloves were required for high-contact care such as bathing and linen changes. The aide stated she had never worn a gown and did not know it was required, while the IP nurse confirmed the precaution applied to all staff, including hospice staff.
A resident alleged being hit on the head by staff after using the call bell and was later found sitting on the floor of the room. The facility generated an internal incident report and conducted an investigation, but the resident’s medical record contained no documentation of the abuse allegation, no notation of an unwitnessed fall or being found on the floor, and no related assessments or interventions. A skin assessment completed the next day showed no tissue injury but did not state why it was performed, and the incident report was kept outside the medical record as a privileged document.
The facility did not ensure that controlled drug counts were accurately maintained and properly signed by two staff members at each shift change. Errors included pre-signing, missing signatures, and signatures being crossed out, with staff and management confirming these documentation lapses during interviews.
Surveyors found that 4 out of 6 coffee mugs on a coffee cart contained a chalky, grayish-brown residue inside, which was easily removed by wiping. The kitchen cook and administrator confirmed the mugs were not clean, and the Certified Dietary Manager indicated that new staff may not have mastered the cleaning process.
A resident suffered bruises and bloody skin tears after a GNA mishandled them while attempting to place them in a wheelchair. The incident was witnessed by the resident's roommate, who confirmed the GNA's actions. Despite having a clear background and abuse training, the GNA refused to provide a statement and reacted inappropriately when questioned by an LPN. The facility's investigation verified the abuse allegation.
The facility staff failed to properly store, label, and date food items in the kitchen's walk-in refrigerator and dry storage room. Observations revealed unlabeled opened containers of food and expired beverages in the refrigerator, and undated canned goods and opened bread in the dry storage. These deficiencies were confirmed by the Dietary Manager and acknowledged by the NHA.
The facility failed to ensure clean drinkware for residents, compromising infection control. Surveyors observed plastic mugs with a chalky film, confirmed by a Dietary Aide and an RN. The Nursing Home Administrator was informed of the issue.
A facility failed to obtain a signature or document refusal for the Notice of Medicare Non-Coverage (NOMNC) for a resident discharged from Medicare Part A services with benefit days remaining. The NOMNC, which informs residents of their rights and protections, was not signed, and there was no documentation of who conducted the notification or if the representative refused to sign. The social services director's documentation was found to be inaccurate, as there was no evidence that the NOMNC was mailed to the resident's representative.
The facility failed to report maintenance issues in resident rooms, resulting in unaddressed deficiencies such as a frayed fall mat, unpainted scrapes, and spackling. The maintenance director was unaware of these issues due to a lack of communication from staff.
A resident with severe cognitive impairment and multiple diagnoses, including depression, was receiving psychotropic medication without a comprehensive care plan. The facility's care plan lacked measurable goals and non-pharmaceutical interventions, focusing only on potential drug-related complications. This deficiency was acknowledged by the DON and Corporate RN during a surveyor discussion.
A facility failed to ensure a resident's representative participated in the care planning process. Despite the resident's severe cognitive impairment and reliance on their daughter as a decision-maker, no formal care plan meeting was held after the MDS assessment. Staff confirmed updates were given, but there was no documentation of a care conference or rescheduling efforts.
A staff member in an LTC facility violated medication administration policy by borrowing Miralax powder from another resident's supply due to a shortage. The facility's policy prohibits administering medications supplied for one resident to another. The staff member claimed the medication was a house-stock item awaiting restocking. The DON expected the staff to restock rather than borrow.
A resident was discharged from a facility without confirmed arrangements for necessary home health services, including IV antibiotics and wound care. The social worker failed to ensure that the referrals were received and services were confirmed with the home health agencies. After discharge, it was discovered that the initial agency did not provide the required services, prompting the social worker to arrange new providers.
A facility failed to implement physician-ordered pressure injury prevention therapies for a resident with a recently healed pressure injury. Despite orders to wear protector boots and float heels, observations showed the resident's heels resting against bed linens without protectors. Staff interviews revealed the resident often refused the booties, and there was miscommunication about replacement booties. The facility's policy required documentation of compliance, but the resident's refusal was not documented in the medical record.
A resident with physical and cognitive limitations was not provided with prescribed bilateral wrist/hand splints to maintain range of motion and prevent contractures. Despite physician orders and documentation indicating the splints were applied, multiple observations showed the resident without them, with hands closed in a fist. The Occupational Therapist confirmed the splints' purpose, and the Nurse Manager acknowledged the discrepancy between records and observations.
The facility failed to provide adequate pain management for two residents by not including pain scale parameters in medication orders and not documenting comprehensive pain assessments. One resident's orders for Acetaminophen and Oxycodone lacked specific pain scale guidance, and another resident's record did not document pain assessment details before administering medication. The DON and clinical services staff acknowledged these deficiencies.
The facility failed to ensure that two staff members completed the controlled drug count at each shift change, as required by policy. A nurse pre-signed the Shift Count sheet, indicating no actual count occurred, and another shift lacked the required signatures. The DON was informed of these deficiencies.
The facility failed to secure medications and needles, as observed in unlocked emergency carts in residents' hallways. An emergency cart in the South Unit was found with open drawers containing epinephrine and a glucagon syringe, while another cart in the North Unit had unsecured needles. The DON confirmed the carts were unlocked and acknowledged the lack of a policy for securing them.
A resident with physical and cognitive limitations was observed not wearing prescribed wrist/hand splints, despite documentation indicating otherwise. The resident's TAR inaccurately recorded splint application during day shifts, which was confirmed by the South Unit Nurse Manager. The discrepancy was discussed with the DON, but no further information was provided.
The facility failed to provide written notification of hospital transfers for two residents, as identified during a recertification survey. In both cases, the residents' representatives were notified via phone, but no written documentation was provided. Interviews with staff confirmed this deficiency, highlighting a lapse in the facility's notification process.
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to a hospital. This deficiency was identified for a resident with moderate cognitive impairment and another resident during a complaint review. Staff confirmed that the policy was discussed verbally but not provided in writing, leading to the deficiency.
A facility failed to document the specific reasons for administering a PRN antianxiety medication and did not implement non-pharmacological interventions before its use. A resident received the medication multiple times, with post-medication assessments indicating ineffectiveness, yet there was no documentation of attempted non-pharmacological interventions or monitoring of behaviors and side effects. The DON confirmed these concerns during an interview.
Failure to Maintain Resident Dignity During Personal Care, Feeding, and Room Entry
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity. Resident #81, who had severely impaired cognition and was totally dependent on staff for most self-care needs including personal hygiene, was observed after breakfast with a blouse and pants soiled with food particles while pacing in the hallway, and facial hair was noted on the chin and upper lip. Later the same day, after lunch, the resident was lying in bed with the blouse still soiled with food particles, lips covered with a brown substance, and facial hair still present on the upper lip and chin. A GNA confirmed the soiled clothing and food residue on the resident's lips and stated he would shave the resident, clean the lips, and change the clothing. Resident #68, who had Parkinson's disease, limited range of motion, and was dependent on others for all care including feeding, was observed being fed lunch by a GNA who stood next to the resident's bed while the resident remained in bed; no chair was near the bed and none was obtained during the observation. Resident #48 reported that a GNA entered the room without knocking, asking permission, or identifying himself, while wearing headphone ear pieces, and removed meal trays. Resident #110 was observed while eating breakfast when a phlebotomist entered the room, announced she was there to draw blood, and began preparing the resident's left hand without first knocking, requesting permission to enter, introducing herself, or asking permission to provide the service.
Advance Directive Information Not Provided
Penalty
Summary
The facility failed to ensure that information to formulate an advance directive was provided to a resident who was documented by the attending physician as able to comprehend information and make decisions. The resident was admitted in late 2025, and a social services admission evaluation noted that a copy of the resident’s advance directive was requested. However, the medical record did not contain a copy of any advance directive, and there was no documentation showing that information had been provided to the resident to formulate one while the resident was still considered capable. During interview, social services staff explained that their usual process is to discuss advance directives within 72 hours of admission when a resident is confirmed to have capacity. When the resident’s record was reviewed with staff, they confirmed that a copy had been requested but not obtained and that there was no documentation of follow-up. Staff also stated the resident no longer had capacity to formulate a new advance directive and had a POA on file, but the POA in the record was financial only and did not address healthcare preferences.
Failure to Provide Required Beneficiary Notice for Skilled Care Discharge
Penalty
Summary
The facility failed to notify residents of their potential financial liability when they were discharged from skilled care. Resident #119, who was admitted for skilled care, was reviewed after surveyors requested a list of residents discharged from skilled care in the prior 6 months and selected three residents for review of beneficiary notification. The documents provided showed that Resident #119 received a Notice of Medicare Non-Coverage indicating the last covered Part A day was 9/03/25 and that the facility initiated discharge from Part A services when benefit days were not exhausted, but no Advance Beneficiary Notice was provided. When the resident’s records were reviewed with the NHA and Business Office Manager, Staff #21 stated that an ABN should have been provided, and both confirmed there was no evidence that one had been given. The NHA later again confirmed the deficiency and stated there was no other evidence to provide.
Late Significant Change MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete Significant Change in Status MDS assessments within 14 days after determining that two residents had experienced a significant decline in condition. For Resident #94, a progress note documented admission to hospice care effective 9/6/25 due to an overall general decline, and the Significant Change in Status MDS was completed and signed on 9/29/25, 23 days after hospice admission and 9 days late. An MDS coordinator confirmed that admission to hospice care required a Significant Change in Status MDS and that the determination date was the day of hospice admission. For Resident #4, the record showed admission to hospice services for failure to thrive effective 11/10/25. The Significant Change in Status MDS was completed and signed on 12/2/25, 22 days after hospice admission and 8 days late. During interview, the MDS coordinator stated that the determination date for the Significant Change in Status was the date of admission to hospice services, and confirmed that this assessment was completed late.
Inaccurate MDS PASRR Entry
Penalty
Summary
The facility failed to ensure that a resident’s MDS assessment was accurately recorded. Record review showed that Resident #81 had a PASRR Level II evaluation indicating a positive result due to a history of developmental delay, and the care plan stated that the resident had a positive PASRR due to developmental delay. However, the resident’s MDS assessment dated [DATE] recorded “no” in section A1500 to the question asking whether the resident was currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. During interview, the social service designee confirmed that Resident #81 had been evaluated as having a positive PASRR II due to developmental delay and stated that the MDS entry was recorded in error.
Failure to Care Plan Resident Behaviors
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for a resident with dementia and behavioral issues. During a lunch observation on the memory care unit, the resident was seen taking food from other residents’ trays and eating it while seated at the same table as two other residents. Record review showed a psychiatry progress note stating the resident had dementia with behavioral issues and that staff observed yelling, agitation, screaming at staff and other residents, and difficulty with redirection, which prompted a psychiatric evaluation request. Additional record review included a social services progress note stating the resident was sometimes agitated, screamed at staff and other residents, and was difficult to redirect. Interviews with the memory care unit manager and a GNA confirmed that the resident’s usual behavior included grabbing other residents’ food, which upset some residents. However, the record review did not show that these behaviors were addressed in the resident’s care plan or that staff interventions were identified to manage the behaviors.
Failure to Document and Hold Care Plan Meetings After Comprehensive Assessments
Penalty
Summary
The facility failed to conduct care plan meetings after completion of comprehensive assessments for 2 residents reviewed for care planning. Resident #5, who had been residing in the facility since early 2024 and was cognitively intact, had a significant change assessment with an ARD of 1/8/26 and an annual assessment with an ARD of 10/30/25. The resident stated that it had been a while since a care plan meeting and did not know who replaced the former social services director. Review of the medical record and progress notes did not reveal documentation of care plan meetings after those assessments, and the social services designee reported that care plan conferences were documented in the evaluation tab as IDT care plan conference summaries. Resident #41, also cognitively intact and residing in the facility since 2024, had an annual assessment with an ARD of 1/14/26 and a quarterly assessment with an ARD of 11/4/25. The resident stated only the first meeting could be remembered when asked about regular care plan meetings. The record contained a note that a care plan meeting was scheduled, and the social services designee stated that a meeting was held on 1/29/26 but was not documented in the medical record. The last documented IDT care plan conference summary in the chart was dated 11/7/25.
Missed Scheduled Showers for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was totally dependent on staff for showers received the scheduled ADL assistance. Resident #110 reported receiving only one shower in the prior 3 weeks during an interview on 2/18/26. The resident’s admission MDS indicated total dependence on staff for showers, and the unit shower schedule showed the resident was to receive 2 showers per week, or 8 showers per month. Review of GNA shower documentation from 1/15/26 to 2/18/26 showed that Resident #110 received two showers in January and one shower in February. A GNA stated the resident was scheduled for 2 showers per week and a bed bath on non-shower days. The unit manager confirmed that the resident received only 3 showers during the reviewed period and stated she would ask nursing assistants why the resident was not offered showers on scheduled days. No additional documentation was provided by survey exit showing that the resident received all scheduled showers during that period.
Failure to Provide Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide activities programs to meet the needs and preferences of a resident with dementia and severely impaired cognition. During observations in the memory care unit, the resident was repeatedly found sitting alone in the dining area with no activity occurring, including being observed with the head bent over and later sleeping in a wheelchair after lunch. A Chronicle paper was on the table during one observation, but no activity program was in progress. Record review showed the resident had diagnoses of dementia and altered mental status, and the care plan identified preferences for time-limited activities of interest such as table activities, old sitcoms, bingo, and music programs. Activity logs from January 1 through February 20, 2026 documented socializing/social events, news & views, music, and bingo, but did not show involvement in television shows or sitcoms as listed in the care plan. Staff interviews confirmed that the resident liked watching TV, but the TV had been moved to another room and had not been working for several months. The activity director acknowledged the concern that activity programs were not being provided based on the resident's needs and preferences.
Inaccurate pressure-relieving mattress settings for residents with pressure injuries
Penalty
Summary
The facility failed to ensure appropriate pressure-relieving device settings for three residents with pressure injuries. Resident #93 had a provider order for a pressure-relieving mattress with settings to be within 10 pounds of the resident’s current weight, but the resident’s last documented weight was 154 pounds and the mattress was inflated to 260 pounds. Resident #57 had the same type of order, with a last documented weight of 172 pounds, but the mattress was inflated to 220 pounds. Resident #118 also had a pressure injury and an order for the mattress to be set within 10 pounds of the resident’s current weight; the resident’s last documented weight was 163 pounds and the mattress was inflated to 220 pounds. During observations, surveyors found the pressure-relieving mattress settings were not accurate for all three residents. Staff #5 and Staff #17 deferred responsibility for calibrating or checking the settings to licensed nursing staff. Staff #18 stated maintenance staff set up the equipment and deferred accuracy questions to the wound nurse. Staff #7 stated the mattress weight setting was based on the resident’s electronic medical record, that she and the unit manager could make adjustments, and that GNAs did not change the settings. Staff #7 also stated audits were completed but not documented, and confirmed during the observation that the three residents’ mattress settings were not accurate.
Oxygen Therapy Given Above Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy was given oxygen at the prescribed rate. Resident #41, who was admitted in early 2024 with a diagnosis including acute respiratory failure with hypoxia, was observed on 2/18/26 receiving oxygen via nasal cannula at 3.5 L/min. A review of the medical record on 2/20/26 showed an oxygen order for 2 L/min, and there was no documentation indicating that the oxygen rate could be titrated or changed. Later on 2/20/26, the resident was observed again receiving oxygen via nasal cannula at 7 L/min. The RN assigned to the resident stated that the oxygen use fluctuated, usually between 4 and 5 L/min and sometimes up to 6 L/min, and reported that the resident had an episode at 1:30 PM with an O2 saturation of 88% due to panic attacks. However, when the record was reviewed with the RN, there was no order to titrate oxygen and no documentation showing an O2 saturation of 88% at 1:30 PM.
Pain Management Documentation Deficiencies
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for two residents who had orders for PRN pain medication and non-pharmacological interventions (NPI) to alleviate pain. Resident #9, who had been residing in the facility since 2024 and had a diagnosis that included chronic pain, had an order for PRN narcotic pain medication with special instructions to document all NPI's as needed. Review of the January 2026 administration record showed the medication was given 8 times, and 3 of those administrations did not document the pain location. Those same entries also lacked documentation showing that NPI's were administered or attempted before the PRN pain medication was given. Resident #41, who was admitted in early 2024 and had diagnoses including osteoarthritis and spondylosis, also had an order for PRN pain medication with special instructions to document all NPI's as needed. Review of the January 2026 administration record showed the PRN pain medication was given 16 times, including 2 administrations for a 0/10 pain score. Those 2 administrations did not include documentation showing that NPI's were administered or attempted before the medication was given. In interviews, the President for Clinical Services reviewed both records and confirmed the findings.
Failure to Address Resident Food-Grabbing Behavior
Penalty
Summary
The facility failed to implement appropriate interventions for a resident with dementia and behavior issues who displayed altered mental status and repeatedly grabbed food from other residents during meals. During a lunch observation on the memory care unit, the resident was seen taking bread from one resident’s tray and then taking cake from another resident’s tray. The second resident yelled and took the cake back from the resident’s hand, and staff moved the resident to the TV room only after the surveyor intervened. Record review showed a psychiatry progress note documenting a diagnosis of dementia with behavior, and a social services note stating the resident was sometimes agitated, screamed at staff and other residents, and was difficult to redirect. Staff interviews confirmed that the resident’s usual behavior included grabbing other residents’ food and upsetting them. The unit manager stated that staff had tried a seating arrangement to prevent the resident from taking other residents’ food during mealtimes, but it did not work, and later showed a new seating arrangement document that was created after the surveyor’s intervention.
Unlocked and Unattended Medication Cart
Penalty
Summary
The facility failed to ensure safe and secure drug storage of resident medications. During a medication administration observation on the 2 North unit, a Licensed Practical Nurse was inside a resident's room with the door shut while the resident medication cart was left unlocked and unattended in front of the room. The surveyor was able to open and access the medication drawers, and the LPN exited the room after hearing the surveyor access the cart and acknowledged that it had been unlocked and unattended. This concern was identified for 1 of 3 resident medication carts observed during the annual recertification survey.
Failure to Assess and Record Food Preferences
Penalty
Summary
The facility failed to conduct a comprehensive assessment of a resident's dietary dislikes and food preferences. Resident #110, who was readmitted to the facility in January 2026, was observed eating breakfast in bed on 2/17/26 and again on 2/18/26 while seated in a wheelchair at the bedside. On both occasions, the resident told the surveyor that eggs were being served despite repeated requests that eggs not be provided, stating that the resident did not like eggs and had told staff multiple times. Record review showed that Resident #110 had a nutrition care plan initiated and revised on 1/20/26 for altered nutrition related to significant weight loss of 7.2% in 30 days with an associated decline in average intake. The care plan included interventions to monitor intake and honor food preferences. A dietary profile completed on 1/27/26 documented the resident's diet order and food texture, but the sections for food preferences and dislikes were left blank. Staff interviews indicated that the dietary manager was responsible for assessing and recording residents' food preferences and dislikes and entering them into the meal ticket system, but that process was missed for Resident #110.
Improper Arbitration Agreement Signature for Resident Lacking Capacity
Penalty
Summary
Informing the resident or representative of the choice to enter into a binding arbitration agreement and the right to refuse was deficient for one resident. The resident was admitted to the facility and later documented by two providers as lacking capacity to make decisions for themselves. The record review also failed to reveal any designated POA, guardian, or surrogate for the resident. Despite the resident's lack of capacity and no identified legal decision-maker, the arbitration agreement in the record showed an electronic signature indicating the resident signed it. The Director of Marketing and Admissions stated that if a resident lacked capacity, she would review the document with the family, but for this resident she was unsure whether the resident or family signed the agreement. Her note stated that she called a family member, discussed the admission packet, and signed the resident's name to the forms due to no POA assignment, while also discussing the forms with the patient as much as possible. She later confirmed that she signed the arbitration agreement on behalf of the resident, and the NHA acknowledged that the agreement was completed incorrectly.
Failure to Use Required PPE for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that all staff donned appropriate PPE for Enhanced Barrier Precautions (EBP) during high-contact resident care. Resident #111, who was admitted in late-2025 and was receiving hospice care, had been placed on EBP since 10/20/25 due to wounds. On 2/17/26 at 10:18 AM, a surveyor observed the resident’s door closed with an EBP sign posted and PPE supplies available on the door. After knocking and opening the door, a staff member was observed providing high-contact care for the resident while wearing gloves but not a gown. The surveyor later learned that the staff member was a hospice aide who had just finished giving the resident a bed bath. During interview, the hospice aide stated that she came to the facility twice a week to provide personal care including bathing, feeding, and personal hygiene, and said she had never worn a gown with the resident, only gloves, because she did not know she had to. The aide then noticed the EBP sign indicating that gown and gloves were required for high-contact care activities, and also confirmed that the resident had wounds. The infection preventionist later stated that the aide definitely should have worn a gown and that all staff, including hospice staff, were aware of the resident’s special precaution.
Failure to Document Abuse Allegation and Fall Event in Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for a resident who alleged physical abuse and was found on the floor. According to the facility’s own incident reporting and investigation for a facility-reported incident, the resident alleged that a staff member answered the call bell and hit the resident on the head. Witness statements obtained during the facility’s investigation indicated that the resident was later found sitting on the floor of the room at approximately 11:40 PM. The allegation was reported to the State Agency and local police, and the facility conducted an investigation and submitted a follow-up report, but they were unable to verify that the resident was struck on the head as alleged. When surveyors reviewed the resident’s medical record, there was no documentation of the resident’s allegation of physical abuse, no notation that the resident had an unwitnessed fall or was found sitting on the floor, and no related assessments or interventions documented in response to these events. An incident report dated the same night indicated the resident was observed sitting on the floor next to the bed, but this document was labeled as privileged, confidential, and not part of the medical record. A skin assessment completed the following day documented no current tissue injury and no skin issues, but did not indicate the reason the assessment was performed. Thus, the medical record lacked required entries regarding the allegation of abuse, the fall event, and any clinical assessments or interventions associated with those events.
Failure to Maintain Accurate Controlled Drug Count Documentation
Penalty
Summary
The facility failed to ensure that controlled drug counts were properly maintained and signed by two staff members at each change of shift, as required. During a review of four drug control books, it was found that two of them contained documentation errors, including pre-signing of shift counts, missing signatures, and signatures that were crossed out. In one instance, a shift count was signed for a future shift before it occurred, and in another, a nurse crossed out her signature after realizing a mistake. Additionally, there were cases where the required signatures for both the outgoing and incoming nurses were missing, and no credible evidence was provided that the count had been performed as required. Interviews with nursing staff and nurse managers confirmed these documentation errors and lapses in procedure. The Director of Nursing acknowledged that pre-signing and incomplete documentation of controlled drug counts had been identified in previous audits and remained an ongoing concern. The findings indicate that the facility did not consistently follow its own procedures for controlled substance accountability, as evidenced by the incomplete and inaccurate shift count records.
Unclean Drinkware Found on Coffee Cart
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary environment to prevent the development and transmission of communicable diseases and infections by not ensuring that residents' drinkware was clean. During an inspection of the coffee serving cart, 4 out of 6 coffee mugs were found to have a chalky, grayish-brown material inside, which was easily removed by gentle rubbing. The kitchen cook initially reported that the cups were clean and ready for use, but upon further inspection, confirmed the presence of the residue. The administrator also confirmed the observation of the unclean mugs. The Certified Dietary Manager acknowledged awareness of the issue and attributed it to new employees not mastering the cleaning process.
Resident Abuse Incident by GNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Geriatric Nursing Assistant (GNA) who physically mishandled a resident. The incident occurred when the GNA attempted to place the resident into a wheelchair, during which the GNA grabbed and wrestled with the resident, resulting in bruises and bloody skin tears on the resident's hands. The incident was witnessed by the resident's roommate, who confirmed that the GNA pushed and pulled the resident into a chair, causing the injuries. The facility's investigation revealed that the GNA had an active license and a clear background check at the time of hire, and had received abuse training earlier in the year. Despite this, the GNA refused to provide a statement about the incident and reacted inappropriately when questioned by a Licensed Practical Nurse (LPN). The facility's final report to the Office of Health Care Quality (OHCQ) confirmed that the abuse allegation was verified through evidence collected during the investigation and interviews with the victim and a witness.
Removal Plan
- Abuse education was provided to all employees
- Resident skin assessments and resident interviews were done
- The employee was immediately terminated
- The GNA was reported to the nursing registry
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility staff failed to properly store, label, and date food items in the kitchen's walk-in refrigerator and dry storage room, as observed during a survey. In the walk-in refrigerator, several opened containers, including a 46-ounce container of thickened Ready Care lemon water, an 8-quart container of applesauce, and a fruit cocktail, were not labeled with the date they were opened. Additionally, a container of gravy was labeled with the wrong date, and two containers of Thick and Easy beverages were found to be expired. These observations were confirmed by the Dietary Manager, Staff #10, who was present during the inspection. In the dry storage room, multiple items were not dated when received, including a 6-pound 9-ounce container of mandarin oranges, three 6.75-pound cans of chili con carne, a 6.6-pound can of sliced white potatoes, six 8-pound cans of concord grape jelly, and two 6.56-pound cans of carrots. Additionally, an opened bag of hamburger buns and an opened bag of hot dog buns were not dated when opened. These findings were also confirmed by Staff #10. The Nursing Home Administrator was informed of these concerns and acknowledged them.
Infection Control Deficiency Due to Unclean Drinkware
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment, which is essential for preventing the development and transmission of communicable diseases and infections. During an observation by two surveyors, it was noted that 11 plastic mugs, designated for resident use, were placed upside down on a tray on a food cart. Upon inspection, two of these mugs had a chalky white/gray film inside, which could be easily removed with gentle finger rubbing. This observation was confirmed by Staff #12, a Dietary Aide, who then removed the soiled mugs. Later, another observation in the South Wing hallway revealed a similar issue with a food cart near resident rooms. Two trays of upside-down plastic mugs were found, and two of the mugs on one tray also had a chalky white/gray film inside. This was confirmed by Staff #11, an RN and South Wing Unit Manager, who removed the soiled mugs and stated they would inform the kitchen of the concern. The Nursing Home Administrator was made aware of these infection control concerns and acknowledged the issue.
Failure to Obtain Signature on NOMNC for Resident
Penalty
Summary
The facility failed to obtain a signature or document refusal to sign the Notice of Medicare Non-Coverage (NOMNC) for a resident who was discharged from Medicare Part A services but had benefit days remaining. This deficiency was identified for one resident who intended to remain at the nursing facility receiving non-skilled care. The NOMNC is a critical document that informs residents of their rights and protections related to financial liability and appeals when being discharged from Medicare services. The facility is required to issue this notice at least two calendar days before the last day of Medicare coverage, allowing the resident or their representative to appeal the decision to terminate paid coverage. In this case, the review of the resident's Beneficiary Notification checklist showed that the NOMNC was dated but not signed, with a statement indicating it was reviewed with the resident's brother via telephone. However, there was no documentation of who conducted the notification or whether the representative refused to sign. A progress note by the social services director claimed that the brother signed the documents, but the NOMNC lacked a signature. An interview with the social services director revealed that the NOMNC was usually mailed to representatives who could not come to the facility, but there was no evidence that this was done for the resident in question. The director admitted that his documentation regarding the signed NOMNC and its distribution was inaccurate.
Failure to Report Maintenance Issues in Resident Rooms
Penalty
Summary
The facility failed to ensure that staff reported areas in need of repair in residents' rooms to the maintenance department, leading to deficiencies in maintaining a safe, clean, and homelike environment. On multiple occasions, surveyors observed issues such as a frayed fall mat and a pillow on the floor in a bathroom, unpainted scrapes on a wall, and unpainted spackling in another bathroom. These observations were made over several days, indicating that the issues were not addressed promptly. The maintenance director confirmed that he was unaware of these issues as they had not been reported through the facility's electronic system for tracking maintenance concerns. Despite checking the system twice daily, the maintenance director had not identified any problems in the affected rooms. The lack of communication between staff and maintenance led to the persistence of these deficiencies, as the maintenance director stated that he could not fix issues he was not informed about.
Failure to Develop Comprehensive Care Plan for Resident on Psychotropic Medication
Penalty
Summary
The facility staff failed to develop and implement a comprehensive, resident-centered care plan for a resident receiving psychotropic medications. The resident, who was admitted to the facility following an acute hospital stay, had severe cognitive impairment and diagnoses including dementia, depression, and adjustment disorder with mixed anxiety and depressed mood. The resident was prescribed Fluoxetine, an antidepressant, which was administered daily. However, the care plan only addressed the resident's response to potential drug-related complications and did not include measurable goals or non-pharmaceutical interventions targeting the resident's symptoms for antidepressant use. The deficiency was identified during a review of the resident's medical records and care plans, which revealed a lack of a comprehensive care plan with specific, measurable goals. The care plan included interventions such as administering medications, observing for side effects, and encouraging the resident to express feelings, but it did not adequately address the resident's targeted symptoms or include non-pharmaceutical interventions. The concerns were acknowledged by the Director of Nurses and the Corporate Registered Nurse during a discussion with surveyors.
Failure to Ensure Resident Representative Participation in Care Planning
Penalty
Summary
The facility failed to ensure the participation of a resident's representative in the care planning process, which was evident for one resident reviewed for care planning. The Minimum Data Set (MDS) assessment, which is crucial for developing a care plan, was completed for the resident, but the facility did not hold a care plan meeting with the resident's representative. The resident, who had severe cognitive impairment, relied on their daughter as the decision-maker. Despite the care plan conference summary report indicating that the representative was unable to participate initially and that a meeting would be rescheduled, there was no evidence that such a meeting was ever rescheduled or held. Interviews with facility staff revealed that while updates were provided to the resident's representative, a formal care conference meeting did not occur. The social services director and a social service designee confirmed that the care conference was conducted over the phone due to the representative's inability to attend physically. However, there was no documentation to support that this phone meeting took place or that any rescheduling efforts were made, as initially noted in the care conference summary report.
Medication Administration Policy Violation
Penalty
Summary
The facility staff failed to adhere to professional standards of practice during medication administration. During an observation, a staff member prepared medications for a resident and, upon discovering a shortage of Miralax powder, borrowed the medication from another resident's supply. This action was contrary to the facility's policy, which explicitly states that medications supplied for one resident should never be administered to another. The staff member later claimed that the borrowed medication was a house-stock item, but acknowledged that the supply was depleted and awaited restocking. The Director of Nursing confirmed that the staff responsible for restocking was absent, but expected the staff member to obtain the key and restock the medication rather than borrowing from another resident's supply.
Inadequate Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure appropriate discharge plans for a resident who was admitted after hospitalization for an infection and required IV antibiotics, wound care, PT, and OT. A care plan was initiated to discharge the resident home with home health care services. However, the discharge planning process was inadequate as the social worker did not confirm arrangements with the home health providers before the resident's discharge. The discharge planning review document lacked contact information for the agencies involved, and the social worker only faxed referrals without confirming receipt or services with the agencies. After the resident's discharge, it was discovered that the IV antibiotic provider no longer offered the required services, and the home health agency had not received the referral. The social worker attempted to rectify the situation by contacting new agencies to arrange for the necessary services. The deficiency was identified when the resident's family reported the lack of follow-up from the agencies, and the social worker confirmed the absence of documentation indicating discussions with the initial agencies.
Failure to Implement Pressure Injury Prevention Therapies
Penalty
Summary
The facility failed to implement physician-ordered pressure injury prevention therapies for Resident #77, who had a recently healed pressure injury on the heel. Physician orders required the resident to wear protector boots while in bed and to float heels every shift to prevent skin breakdown. However, multiple observations during the survey revealed that the resident was not wearing heel protectors, and the heels were resting against the bed linens. Interviews with staff indicated that the resident often refused to wear the booties, and there was a miscommunication regarding the availability and use of replacement booties when the original ones were sent to the laundry. The facility's policy on pressure injury prevention required documentation of compliance with interventions in the medical record. However, a review of Resident #77's progress notes failed to show documentation of the resident's refusal to wear the heel protector booties. Interviews with the physician and nursing staff confirmed the lack of documentation and miscommunication regarding the use of heel protectors. The Director of Nursing and the president of Clinical Services acknowledged the concerns raised during the survey, but no additional information was provided before the survey concluded.
Failure to Apply Prescribed Splints for Resident's Range of Motion Maintenance
Penalty
Summary
The facility staff failed to provide appropriate treatment to maintain a resident's range of motion, as evidenced by the lack of application of prescribed bilateral wrist/hand splints for a resident with physical and cognitive limitations. The resident, who was totally dependent on staff for activities of daily living, had a physician's order for wearing the splints to prevent further contractures and protect the hands from injury. Despite this order, multiple observations over several days revealed that the resident was not wearing the splints, and their hands were consistently observed to be closed in a fist. The Occupational Therapist confirmed the purpose of the splints was to maintain hand alignment and prevent worsening of finger contractures. However, the South Unit Nurse Manager acknowledged the inconsistency between the treatment administration record, which documented that the splints were applied, and the surveyor's observations. The nurse manager confirmed the concerns regarding the non-application of the splints during the observed periods.
Deficiency in Pain Management Documentation and Parameters
Penalty
Summary
The facility failed to ensure proper pain management for two residents by not including pain scale parameters in as-needed pain medication orders and not documenting comprehensive pain assessments. For one resident, the medication orders for Acetaminophen and Oxycodone lacked specific pain scale parameters to guide administration. The resident was observed in pain after a dressing change, and the LPN indicated that the resident requested Oxycodone when their pain level was 6, despite the absence of a formal pain scale in the orders. The Director of Nursing and the Senior President of Clinical Services acknowledged the omission of pain scale parameters in the Oxycodone order. Another resident was observed expressing severe back pain, yet their medical record did not document a pain assessment, including the location and type of pain, before administering pain medication. The resident's medication administration record showed pain medication was given, but follow-up pain scales were recorded as 0 without prior documentation of non-pharmacological interventions. The LPN reported implementing non-pharmacological interventions only if the resident continued to complain after receiving medication. The regional director of clinical services confirmed that nurses were expected to document pain assessments and non-pharmacological interventions before administering as-needed pain medications.
Failure to Complete Controlled Drug Count at Shift Change
Penalty
Summary
The facility failed to ensure that two staff members completed the controlled drug count at the change of each shift, as required by their Controlled Substance Storage policy. This deficiency was identified during a review of the facility's drug control books, where it was found that one out of three books did not have the required documentation. Specifically, the Shift Count documentation for the Section 1 North medication cart showed that a shift count was completed and signed by the Coming On Duty Nurse and the Going Off Duty Nurse. However, further review revealed that the Going Off Duty Nurse had pre-signed the document, indicating that no actual count had occurred at that time. During an interview, the nurse confirmed that pre-signing the Shift Count sheet was her standard practice, as she had been instructed to do so. The unit nurse manager intervened during the interview to correct this practice, instructing the nurse to sign the Shift Count at the time of the count. Additionally, a review of the Shift Count documentation for another shift failed to reveal a signature for the offgoing nurse, further indicating that the required procedure was not followed. The Director of Nursing was informed of these findings, highlighting the issue of staff pre-signing the shift count documentation.
Unsecured Emergency Carts with Medications and Needles
Penalty
Summary
The facility failed to ensure the security of medications and needles, as evidenced by observations of unlocked emergency carts in residents' hallways. During a survey, it was observed that the lower drawer of an emergency cart located in the South Unit near the nurse's station was slightly open and not locked. The top drawer of the same cart was also found open, containing an amp of epinephrine and a glucagon syringe. A similar observation was made on the North Unit, where another emergency cart was found unlocked with unsecured needles in the third drawer. The Director of Nursing confirmed the observations, acknowledging that the emergency carts were unlocked and the medications unsecured. A nurse reported that the emergency cart is not kept locked and is stocked by the night shift. The Director of Nursing also admitted that the facility lacked a policy regarding the security of emergency carts, which contributed to the deficiency observed during the survey.
Inaccurate Documentation of Splint Application
Penalty
Summary
The facility failed to ensure that staff documented only the interventions that were completed, specifically regarding the application of wrist/hand splints for a resident with physical and cognitive limitations. The resident was dependent on staff for activities of daily living and had an order to wear bilateral wrist/hand splints for up to six hours daily to reduce the risk of further contracture, with skin integrity checks required pre- and post-wear. However, multiple observations over several days revealed that the resident was not wearing the splints as ordered, and their hands were consistently observed to be closed in a fist. Despite these observations, the treatment administration record (TAR) inaccurately documented that the splints were applied during the day shifts on two specific days. The South Unit Nurse Manager confirmed the discrepancy between the TAR and the actual observations, acknowledging that the splints were not applied as documented. The Director of Nursing was informed of these concerns, but no additional information was provided before the survey concluded.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to residents and/or their representatives upon transfer to the hospital. This deficiency was identified during a recertification survey for one resident and one complaint. In the case of Resident #59, the medical record review showed that the resident experienced difficulty breathing and was sent to the emergency room on the attending provider's order. Although the resident's representative was notified via phone, there was no evidence of written notification regarding the transfer and its reason. Interviews with staff, including a unit manager and the nursing home administrator, confirmed that notifications were made via phone calls and not in writing. Similarly, for Resident #301, the clinical record review revealed a transfer to the emergency room, but no written notice of transfer was found in the medical record. An interview with the Director of Nursing confirmed the absence of such documentation, acknowledging this as a deficiency. The lack of written notification in both cases highlights a failure in the facility's process for informing residents and their representatives about hospital transfers.
Failure to Provide Written Bed Hold Policy Notice
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the facility's bed hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification survey for one resident and one complaint. Specifically, Resident #59, who had been living in the facility since November 2022 and had moderate cognitive impairment, was transferred to the hospital due to difficulty breathing. The facility did not provide a written copy of the bed hold policy to the resident's representative, as confirmed by a unit manager and the director of nursing. The staff indicated that the policy was discussed verbally but not provided in written form upon transfer. Additionally, a review of another resident's clinical record revealed a similar deficiency. The resident was transferred to the emergency room, and there was no evidence that a written bed hold policy notice was provided to the resident or their representative. The Director of Nursing confirmed the absence of the document in the resident's medical record, acknowledging this as a deficiency. The facility's practice of discussing the policy verbally without providing written documentation upon transfer led to these findings.
Failure to Document PRN Psychotropic Medication Use and Implement Non-Pharmacological Interventions
Penalty
Summary
The facility failed to document the specific reason for administering a psychotropic medication prescribed as needed (PRN) and did not implement non-pharmacological interventions before administering the medication. This deficiency was identified during a recertification survey for a complaint involving a resident who was allegedly chemically restrained with an antianxiety medication. The attending provider had ordered the medication to be administered every 12 hours PRN for agitation/anxiety, but the medical records did not specify the behaviors that warranted the medication's use. The medication administration record (MAR) for the resident showed that the antianxiety medication was administered on several occasions, with post-medication assessments indicating that the medication was ineffective. Despite this, there was no documentation of non-pharmacological interventions attempted before administering the medication, nor were there records of interventions implemented following the ineffective assessments. Additionally, there was a lack of ongoing monitoring of the resident's behaviors and side effects related to the medication use. The director of nursing confirmed these concerns during an interview.
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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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