Glen Meadows Retirement Com.
Inspection history, citations, penalties and survey trends for this long-term care facility in Glen Arm, Maryland.
- Location
- 11630 Glen Arm Road, Glen Arm, Maryland 21057
- CMS Provider Number
- 215278
- Inspections on file
- 14
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Glen Meadows Retirement Com. during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and known elopement risk were able to leave secure areas undetected due to failures in the WanderGuard alarm system and inadequate monitoring. The alarm system did not activate when the residents exited, and staff were unaware of their absence until they were found outside or in another area. Documentation and evaluation processes were also insufficient, contributing to the lack of effective supervision.
Surveyors found expired food items in the kitchen, an overdue ice machine filtration cartridge, and inconsistent dishwashing sanitization temperatures. The CDM confirmed that expired items were not discarded as required, and the Maintenance Manager acknowledged the overdue cartridge replacement. Temperature logs and direct observation showed the dishwashing machine often failed to reach the required 180°F for final rinse, with staff not consistently monitoring the gauges.
Facility staff did not ensure an effective QAPI program was in place to identify and address quality concerns, as evidenced by the lack of discussion and corrective action for incidents such as a resident's elopement, employee-to-resident abuse, and repeated controlled medication documentation errors. The QAPI meetings and documentation failed to include detailed reviews or plans for these issues, and the NHA confirmed these deficiencies were not systematically addressed.
A resident was physically struck on the forearm by a GNA after reaching for a laundry basket, as witnessed and documented by staff. The resident confirmed the incident through gestures during an interview. Facility leadership acknowledged the event and discussed whether the act was intentional, but the smacking was confirmed to have occurred.
The facility did not submit initial reports of suspected abuse involving two residents to the State Survey Agency within the required two-hour timeframe. In both cases, staff and family members reported witnessing physical abuse by GNAs, but the reports were delayed by several hours, contrary to established protocols and staff training.
The facility did not thoroughly investigate or document three separate incidents: an alleged abuse where a resident was reportedly struck by a caregiver, an elopement where a resident left a secure area despite wearing a WanderGuard that failed to activate alarms, and a medication error involving uncounted liquid lorazepam and delayed reporting. In each case, required assessments, root cause analyses, and staff education were incomplete or missing, as confirmed by interviews and record reviews.
Nursing staff did not consistently follow professional standards for counting and documenting controlled medications, including failing to properly count liquid lorazepam and not reporting a medication discrepancy in a timely manner. Review of accountability sheets revealed multiple missing nurse signatures and incomplete documentation across several shifts, with the DON confirming these lapses in required procedures.
A resident developed new respiratory symptoms, including congestion and difficulty breathing, which led to new medical interventions such as cough medicine, a chest x-ray, and oxygen. Despite these changes, the care plan was not updated to address the resident's respiratory issues, as confirmed by staff interviews and record review.
Facility staff did not develop a baseline care plan or provide a copy of the care plan and medication list to a resident or their representative within 48 hours of admission. Review of the electronic health record and staff interviews confirmed the absence of the required documentation.
A resident was ordered to wear a WanderGuard device to prevent elopement, but staff did not update or implement a person-centered care plan addressing the device's use. Nursing documentation lacked details on the rationale, location, and care interventions for the device, and the electronic medical record did not contain an active care plan reflecting the current use of the WanderGuard.
A resident identified as at risk for pressure ulcers developed a Stage 2 pressure injury on the right heel, which progressed to an unstageable ulcer due to a lack of timely wound provider assessment and delayed implementation of new interventions. Facility staff confirmed that no new physician orders or wound care measures were initiated until several days after the ulcer was first documented, allowing the condition to worsen.
Facility staff did not have an effective system to monitor or respond to significant weight fluctuations in a resident, as evidenced by unaddressed and undocumented changes in body weight. Staff interviews confirmed that expected procedures for reweighing and reporting were not followed, and the DON acknowledged the lack of documentation and response.
A resident with multiple diagnoses, including bipolar disorder and Parkinson's, was prescribed several psychotropic medications without corresponding physician orders for behavior or side effect monitoring. Both the DON and ECSSM confirmed that such monitoring is required, but review of the records showed it was not in place, resulting in a deficiency.
A resident receiving Oxycodone for pain management had multiple discrepancies between the controlled substance count sheet and the MAR, with several doses documented as given on one record but not the other, and inconsistencies in the timing and order of entries. Interviews with an LPN and the DON confirmed that both records should match, but this was not consistently done.
A resident receiving hospice care had elevated blood glucose levels and frequently refused fingerstick checks. The consulting pharmacist recommended changes to the insulin dose and a reduction in fingerstick frequency, but the recommendation was not addressed by a provider, as there was no response, signature, or date on the form. The DON confirmed that the facility did not review or respond to the pharmacist's recommendations within the expected timeframe.
Facility staff did not ensure consistent attendance of required QAA committee members at monthly meetings, with the Medical Director, DON, and Infection Preventionist each missing one or more meetings as confirmed by the NHA through attendance records.
Two residents were not properly offered or documented for influenza and pneumococcal vaccinations. One resident lacked records for both vaccines, and another had no documentation of being offered or educated about the pneumonia vaccine, with consent forms left incomplete and no supporting documentation in the medical record.
A review of employee health files revealed that one registered nurse's COVID-19 vaccination status was not documented. Staff interviews confirmed that the facility did not maintain COVID-19 immunization records for employees after discontinuing vaccine administration.
Surveyors found that the facility did not have a required transfer agreement with a local hospital, as confirmed by the NHA during documentation review and staff interviews.
Failure to Prevent Elopement of Cognitively Impaired Residents Due to Ineffective Monitoring and Alarm Systems
Penalty
Summary
The facility failed to maintain an effective system to prevent residents with cognitive impairments from leaving the premises without appropriate supervision. Two residents with known exit-seeking and elopement behaviors were able to leave secure areas of the facility undetected. One resident, who had a history of severe cognitive impairment and multiple prior elopement incidents, was able to exit the building after dinner and was found outside near the facility van. The WanderGuard system, which was intended to alert staff and prevent such incidents, did not trigger an alarm when the resident exited, and only recorded an event when the resident was escorted back inside. Staff documentation for this incident was also found to be mixed with records from a previous year, and no new elopement evaluation was completed after the incident. Another resident, also with severe cognitive impairment and a history of wandering, was found in the assisted living library after having previously eloped from the nursing home building. This resident had a WanderGuard bracelet in place, but the system failed to alarm when the resident passed through a monitored door. The alarm only activated when the resident was brought back through the door by staff. Interviews with facility leadership and maintenance staff revealed that the WanderGuard alarm system's audio alert was faint and not easily heard from a distance, and that the system was not integrated with staff phones, relying instead on pagers for notification. Observations confirmed that the physical environment outside the main entrance posed multiple hazards, including active roadways and parking areas. The facility's elopement evaluation process was found to be inadequate, as it was only used to determine the need for a WanderGuard and not updated after each incident. Staff interviews confirmed a lack of understanding regarding the need for post-incident evaluations. The combination of ineffective monitoring, unreliable alarm systems, and insufficient post-incident assessment contributed to the failure to provide adequate supervision and prevent accidents for residents at high risk of elopement.
Removal Plan
- A team member will be present monitoring the front entrance doors at nursing desk and the door exiting the healthcare center level of living and entering assisted level of living 24 hours a day, 7 days a week to ensure constant visual monitoring of individuals exiting the community until a mechanism is installed to create immediate notification to community staff for unauthorized exits.
- Install a mechanism to create immediate notification to community staff for unauthorized exits.
- Consult a security company to explore solutions to increase door security related to unauthorized exits and have a senior technician assess the situation.
- Educate current community staff of all disciplines on the immediate process change related to door security.
- Audit the front entry door monitoring and door between assisted living and nursing home daily by NHA or designee.
- Submit audit results for review and recommendation to the Quality Assurance Performance Improvement Committee.
Deficiencies in Food Storage, Ice Machine Maintenance, and Dishwashing Sanitization
Penalty
Summary
Surveyors identified several deficiencies in the facility's food service operations during an inspection. Expired food items, including various spices, pork, and frozen cookies, were found in the kitchen with labels indicating they were past their use-by dates. The Certified Dietary Manager (CDM) confirmed that these items should have been discarded according to facility policy, which requires opened items to be labeled and disposed of once expired. The CDM acknowledged responsibility for ensuring compliance with these procedures and disposed of the expired items during the surveyor's observation. Additionally, the ice machine's filtration cartridge was found to be overdue for replacement. The label on the cartridge indicated it should have been replaced six months after installation, but both the CDM and the Maintenance Manager confirmed it had not been replaced as required. The Maintenance Manager, whose initials were on the installation label, acknowledged that the replacement was overdue. The facility also failed to consistently maintain required temperature levels for dishwashing sanitization. Observations showed that the dishwashing machine's final rinse temperature did not always reach the required 180°F, with several loads registering below this threshold. Review of the dishwasher temperature logs revealed that a significant number of final rinse temperatures documented over the past month were below the required level. Neither the CDM nor the dishwasher staff were observed monitoring the temperature gauges during operation, and the CDM confirmed that staff had been trained to do so but were not consistently following this practice.
Failure to Implement Effective QAPI Program for Quality Concerns
Penalty
Summary
Facility staff failed to maintain an effective Quality Assurance Performance and Improvement (QAPI) program capable of identifying and correcting quality concerns. During the recertification and complaint survey, surveyors found that the facility's QAPI meetings, while held monthly, did not address specific incidents such as resident elopement, employee-to-resident abuse, or issues with controlled medication documentation. The QAPI binder contained only general incident counts without detailed discussions or corrective action plans for these events. When questioned, the Nursing Home Administrator (NHA) was unable to provide evidence that these incidents were reviewed or addressed through the QAPI process. Specific incidents were cited, including a resident's elopement, an employee-to-resident abuse case, and repeated failures in controlled medication documentation by nursing staff. The NHA confirmed that these issues were either not discussed or not documented in the QAPI process, despite being self-reported and noted in follow-up reports. The lack of a systematic approach to identifying and correcting these deficiencies demonstrated the facility's failure to ensure an effective QAPI program was in place.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a geriatric nursing assistant (GNA) was observed by another staff member to have open-hand smacked a resident on the left forearm after the resident reached for and would not let go of a laundry basket. The incident took place in the hallway outside a resident room, and was documented in the facility's investigation file, including a signed interview with the witnessing staff member. The resident, when interviewed, demonstrated a swiping motion and indicated through gestures that they had been hit, further corroborating the account of the incident. The facility's policy defines physical abuse as including actions such as hitting and slapping, and the incident was discussed by facility leadership, who acknowledged the smacking occurred. Interviews with the DON and NHA revealed a focus on whether the act was intentional, but both confirmed the event took place as described. The report does not mention any relevant medical history or specific condition of the resident at the time of the incident, but it is clear that the resident was in a wheelchair and able to communicate non-verbally about the event.
Failure to Timely Report Allegations of Abuse to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse to the State Survey Agency, specifically the Office of Health Care Quality (OHCQ), as required. In the first incident, a staff member observed a geriatric nursing assistant (GNA) allegedly smacking a resident on the forearm. The incident was observed at approximately 7:30 AM, but the initial report to OHCQ was not submitted until almost four hours later, exceeding the required two-hour reporting timeframe. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Extended Care Services Support Manager (ECSSM) confirmed that the report was not submitted within the mandated period, despite staff being educated on immediate reporting protocols. In the second incident, a family member reported witnessing a male caregiver push and hit another resident. The facility became aware of this allegation at 9:50 AM, but the initial report was not submitted to OHCQ until 4:25 PM, approximately 6.5 hours later. The DON confirmed during an interview that this report was also not submitted within the required two-hour timeframe. Both incidents demonstrate a failure to adhere to state-mandated timelines for reporting suspected abuse, as evidenced by documentation and staff interviews.
Failure to Investigate and Document Abuse, Elopement, and Medication Error Incidents
Penalty
Summary
The facility failed to thoroughly investigate and document three separate incidents involving residents. In the first incident, a family member reported that a male caregiver allegedly pushed and struck a resident. Although the facility's initial self-report stated that the resident was immediately assessed and had no injuries, there was no evidence of any assessment or related progress notes in the resident's medical record during the investigation period. Interviews with the DON and NHA confirmed that the required assessment was not completed or documented as indicated in the self-report. In the second incident, a resident eloped from the secure area of the healthcare building while wearing a WanderGuard bracelet, which failed to activate the door alarms. The facility's investigation records did not include documentation of a root cause analysis or an audit of other residents' WanderGuard devices. Additionally, education regarding the elopement incident was not provided to all required staff, as only a portion of the nursing staff received in-service training. The third incident involved a medication error where a controlled substance (liquid lorazepam) was not properly counted by nursing staff, and a discrepancy was not reported in a timely manner. The facility's investigation revealed that not all nurses involved received the required education, and the DON did not conduct a thorough audit of controlled medications, nor was there an audit form available. These failures demonstrate a lack of comprehensive investigation and follow-through on corrective actions for reported incidents.
Failure to Follow Professional Standards for Controlled Medication Counts
Penalty
Summary
Facility nursing staff failed to adhere to professional standards of nursing practice regarding the counting and documentation of controlled medications. Specifically, on one occasion, liquid lorazepam for a resident was not properly counted by an LPN and an RN, and a discrepancy in the medication amount was not reported in a timely manner by another RN. The facility's investigation revealed that during a shift change, the required process of two nurses verifying and counting controlled medications, including those stored in the medication refrigerator, was not followed. When a discrepancy of 15ml was discovered, the appropriate reporting protocol was not immediately followed, as the nurse contacted another staff member by phone instead of notifying the Director of Nursing (DON) as required. Further review of the facility's controlled medication accountability signature sheets for two medication carts over a two-week period showed multiple instances where required nurse signatures and total item counts were missing. These omissions occurred across various shifts and dates, indicating a pattern of incomplete documentation and lack of adherence to established procedures for controlled medication accountability. The DON confirmed that the expectation was for two nurses to verify and document the counts with signatures at each shift change, and acknowledged the deficiencies identified during the review.
Failure to Update Care Plan for New Respiratory Issues
Penalty
Summary
The facility failed to revise the interdisciplinary care plan to address a resident's new respiratory issues. Medical record review showed that the resident returned from an outing in stable condition but subsequently developed congestion and a dry cough, which led to the ordering of cough medicine and a chest x-ray. Progress notes documented that the resident was unable to clear mucus and required oral suctioning. Later, the resident experienced difficulty breathing, prompting the application of oxygen and a call to 911. The resident, who had a DNR order, expired before emergency services arrived. Despite these significant changes in the resident's respiratory status and the initiation of new interventions, the care plan was not updated to reflect the resident's recent respiratory issues. Interviews with facility staff confirmed that the expectation was for the care plan to be revised in response to such changes, but documentation showed the care plan had not been updated since before the onset of the respiratory symptoms.
Failure to Develop and Provide Baseline Care Plan Upon Admission
Penalty
Summary
Facility staff failed to develop a baseline care plan and did not provide the resident or their representative with a copy of the baseline care plan and medication list within 48 hours of admission, as required. Medical record review on 3/31/25 revealed that the resident did not have a baseline care plan documented in the electronic health record. During interviews, the DON confirmed that no baseline care plan was present and was unable to provide a copy, stating that the nurse is responsible for completing and having the care plan signed, after which it should be scanned into the electronic record. Further interviews with the ADON and Administrator confirmed that there was no documentation of a completed baseline care plan for the resident.
Failure to Update Care Plan for Resident with WanderGuard Device
Penalty
Summary
Facility staff failed to update and implement a person-centered care plan for a resident who was ordered to wear a WanderGuard safety device to prevent elopement. The medical record review showed that an order for the WanderGuard was written, but there was no nursing documentation explaining the rationale for the device, its location, or an active care plan guiding staff on how to care for the resident while the device was in use. The treatment administration record indicated that staff signed off on the device's presence but did not document its site of application. Further review of the resident's care plan in the electronic medical record system revealed there was no active care plan addressing the use of the WanderGuard. The DON confirmed during interview that a care plan should have been in place for the safety device. An inactive behavioral care plan was provided, but it did not reflect the current use of the WanderGuard or include updated interventions. Previous documentation noted the device's placement on the resident's wheelchair, but this information was not current or incorporated into an active care plan.
Failure to Timely Assess and Intervene for Pressure Ulcer Development
Penalty
Summary
The facility failed to implement timely and appropriate measures to prevent the development and worsening of a pressure ulcer for a resident who was at risk due to decreased mobility and occasional incontinence. Upon admission, the resident was identified as being at risk for pressure ulcers, and a care plan was established to maintain skin integrity. Despite this, the resident developed an open blister on the right heel, which was documented as a Stage 2 pressure ulcer within two days. There was no evidence of wound provider assessment or new physician orders for wound care interventions until ten days after the initial identification of the pressure injury. During this period, the resident's condition progressed from a Stage 2 pressure ulcer to an unstageable pressure ulcer, as confirmed by the wound nurse practitioner's first assessment. Facility staff confirmed that the resident was not seen by the wound provider and did not receive new interventions until after the ulcer had worsened. The lack of timely assessment and intervention was acknowledged by facility leadership as a significant concern.
Failure to Monitor and Respond to Significant Weight Changes
Penalty
Summary
Facility staff failed to have a system in place to monitor and respond to significant changes in a resident's weight. Medical record review showed that a resident experienced notable fluctuations in body weight over a short period, including an 8.3% loss within nine days and a subsequent 23% gain, with no documentation or follow-up regarding these changes. The dietitian noted suspected errors in weight entries but there was no evidence in the medical record that these discrepancies were investigated or addressed in a timely manner. Interviews with staff confirmed that while there was an expectation to reweigh and report significant weight changes, there was no documentation that this process was followed for the resident in question. The DON verified that the facility did not document monitoring or response to the resident's weight fluctuations, confirming the deficiency in the facility's system for managing residents' nutritional status.
Failure to Provide Required Behavioral Health Monitoring for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to provide necessary behavioral health monitoring for a resident who was prescribed multiple psychotropic medications. Medical record review revealed that the resident, who had diagnoses including bipolar disorder, Parkinson's disorder, a history of falls, muscle weakness, and unsteadiness, was receiving Seroquel, Divalproex sodium ER, and Mirtazapine. Despite these medications, there were no physician orders for behavior or side effect monitoring documented in the resident's records. During interviews, both the Director of Nursing (DON) and the Extended Care Services Support Manager (ECSSM) confirmed that behavior monitoring is required for any resident on psychotropic medications and that such orders should be present and documented in the medication administration record. Upon review of the resident's physician orders, both staff members acknowledged that the required behavior monitoring order was missing for this resident, confirming the deficiency.
Failure to Reconcile Controlled Substance Administration Records
Penalty
Summary
The facility failed to maintain drug records in a manner that allowed for reconciliation of dispensed and administered medication for a resident who was admitted for recovery from a right digital radial fracture and was prescribed Oxycodone 2.5mg every 6 hours as needed for pain. A review of the resident's Medication Administration Record (MAR) and controlled substance records for March 2025 revealed multiple instances where the controlled substance records indicated that Oxycodone was administered, but there was no corresponding documentation in the MAR. Specific dates and times were identified where this discrepancy occurred, and there were also inconsistencies in the documentation for a particular day, with times and doses not matching between the two records and not being recorded chronologically. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the expectation was for nurses to document administration of controlled medications on both the MAR and the controlled substance count sheet. The DON acknowledged the discrepancies and agreed that the two records should match, validating the surveyor's findings of incomplete and inconsistent documentation for the administration of a controlled substance.
Failure to Timely Respond to Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to respond in a timely manner to recommendations made by the consulting pharmacist for a resident reviewed for unnecessary medication use. The pharmacist had recommended adjustments to the resident's insulin regimen and frequency of fingerstick blood glucose monitoring, noting that the resident's blood sugar levels were elevated and that the resident, who was on hospice care, often refused fingersticks. The recommendation form in the resident's medical record lacked any physician response, signature, or date, indicating that the recommendations were not addressed as required. During review with the Director of Nursing, it was confirmed that the facility did not review and respond to the Monthly Recommendation Report within the expected timeframe.
Failure to Ensure Required QAA Committee Member Attendance
Penalty
Summary
Facility staff failed to ensure that all required members of the Quality Assessment and Assurance (QAA) committee consistently attended the monthly QAA meetings. Review of facility records from February 2024 to February 2025 showed that the Medical Director missed one meeting, the Director of Nursing missed two meetings, and the Infection Preventionist missed three meetings. These attendance lapses were confirmed by the Nursing Home Administrator during an interview and review of the QAA committee attendance sheets. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that all residents were properly offered and documented for influenza and pneumococcal vaccinations. Specifically, one resident admitted in February 2025 did not have records of receiving the flu vaccine for the current season, nor any documentation regarding the pneumococcal vaccine. Interviews with the Assistant Director of Nursing (ADON) and a corporate support manager revealed that delays in updating vaccination status were attributed to difficulties in reaching responsible parties for consent, but there was no documentation in the resident's medical record to reflect these efforts or the resident's vaccination status. Additionally, another resident's medical record lacked documentation of the pneumonia vaccination status. Although the responsible party had provided telephone consent for the flu vaccine, there was no evidence that education or an offer for the pneumococcal vaccine was provided, as indicated by the incomplete consent form. The ADON confirmed that the pneumonia vaccine status was not updated and that there was no documentation supporting that education regarding the pneumococcal vaccine had been given.
Failure to Document Employee COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure proper documentation of employees' COVID-19 vaccination status, as evidenced by the absence of a COVID-19 vaccination record for one registered nurse hired in November 2024. During a review of five randomly selected employee health files, it was found that the immunization record for this nurse did not include any documentation of COVID-19 vaccination. Interviews with the ADON and corporate supporting manager confirmed that the facility did not maintain this documentation, with the ADON stating that records were not kept since the facility no longer offered the COVID-19 vaccine. The lack of documentation was validated by staff during the survey.
Lack of Required Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a transfer agreement with a local hospital as required by federal regulations. During an extended survey, the surveyor requested documentation of a transfer agreement, and the Nursing Home Administrator confirmed that no such agreement existed between the facility and a local hospital. This deficiency was identified through review of documentation and staff interviews. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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