Ingleside At King Farm
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 701 King Farm Boulevard, Rockville, Maryland 20850
- CMS Provider Number
- 215353
- Inspections on file
- 14
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Ingleside At King Farm during CMS and state inspections, most recent first.
Unsanitary conditions were observed in the dish machine room during the annual survey. Steam was escaping from both ends of the high temperature conveyor dish machine and scattering throughout the room, and excessive black buildup was seen on the vent stacks, dropdown ceiling tile edges, and drywalls. Staff confirmed the dish machine room would be scheduled for deep cleaning and maintenance review.
Missed Required Attending Provider Visits: A resident on hospice care was not documented as being seen face-to-face by an attending provider at least every 60 days. The chart showed a 166-day gap between provider visits, and interviews confirmed the resident’s record lacked documentation for the period in question, despite the provider stating visits were alternated with a NP.
A resident receiving duloxetine and other medications had a pharmacist recommendation to document the need for the antidepressant and consider a GDR. The attending provider did not act on the recommendation for an extended period, even though additional MRRs were completed before it was addressed, and the DON confirmed the delay in review and response.
Essential kitchen equipment was not maintained in proper operating condition during the annual survey. Surveyors observed a nonfunctional hand sink by the food prep area with a posted notice that the faucet had not worked since earlier in the month, and staff confirmed a work order had been submitted. Surveyors also observed a Continental undercounter freezer turned off, and staff confirmed the unit was nonfunctional and had a work order submitted.
The facility failed to adhere to professional standards for food storage, as observed by a surveyor. Opened and unlabeled food items, uncovered containers, and expired products were found in various storage areas, including the produce refrigerator and meat/fish cooler. The Certified Food Services Manager confirmed these findings, which were contrary to the facility's policy requiring proper labeling and disposal of expired foods.
A resident's private duty aide improperly used a gait belt as a restraint to prevent the resident from getting up out of their wheelchair. This incident was identified by a nurse and confirmed through a facility investigation, which substantiated the improper use of physical restraints. The facility had policies requiring PDAs to follow its procedures, but the aide's actions were contrary to these guidelines.
A resident with cognitive impairment was found with a swollen leg and bruise, and the facility failed to report the injury within the required 2-hour timeframe and delayed submitting investigation results. The initial report was submitted 24 hours after discovery, and the investigation results were submitted 6 days later, both outside the required timeframes.
Facility staff failed to ensure a resident received routine dental care. A resident's medical record indicated an order for a dental evaluation due to a broken tooth, but there was no documentation of prior dental services. The NHA stated that the facility does not provide routine dental services, and residents are informed to arrange their own care, with the facility only arranging appointments when a concern is identified.
The facility failed to document a dental treatment plan for a resident and did not complete beneficiary notifications correctly for two residents. One resident's discharge lacked a Notice of Medicare Non-Coverage, and another's SNFABN was incomplete. The NHA and Director of Social Services acknowledged these deficiencies.
The facility staff failed to maintain a homelike environment, as evidenced by damaged drywall behind residents' beds in three rooms observed during a medication administration assessment. A surveyor noted marring on the walls, which was confirmed by an RN and an LPN. The LPN admitted not noticing the damage until it was pointed out, and the RN had been on vacation prior to the survey. The staff used an app to report maintenance issues, but the damage had not been reported before the surveyor's observation.
A facility failed to revise a resident's care plan to address communication needs, despite frequent refusal to wear hearing aids and updated recommendations from an audiologist. The resident, with dementia and hearing deficit, required visual cues for communication. The care plan did not reflect these needs or the resident's refusal to use hearing aids, as confirmed by the ADON.
The facility failed to maintain professional standards in monitoring resident weights, as two residents experienced significant weight loss without proper follow-up. A resident lost 10.17% of their weight, and another lost 6.99% within a month. The Registered Dietician identified the issues but faced delays in reweighing and lacked documentation for weekly reweigh orders. Additionally, there was no documentation of refusals or immediate reweighs to confirm weight accuracy.
A facility failed to ensure an LPN on the memory care unit completed necessary dementia training. The LPN's last documented training had expired, and the recent training lacked detailed dementia care content. The HR Director confirmed annual training assignments, but the completed training only mentioned cognitive impairment, not dementia.
The facility staff did not update the staffing sheets on two units after changes to the schedule. A GNA was documented as working but had called out, and two GNAs called in to work were not reflected on the sheets. The DON acknowledged that updates are supposed to be transcribed to the daily staffing sheet, which was not done.
A facility's pharmacy failed to administer a prescribed supplement with a dosage for a resident during a medication administration survey. The blister package containing Vitron C lacked a specified dose, although the MAR indicated it was to be given twice daily for anemia. An LPN acknowledged having called the pharmacy to verify the dose. A pharmacist confirmed that the pharmacy typically does not send medications without a dose and expressed willingness to add the strength of the supplement if needed.
Unsanitary Conditions in Dish Machine Room
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public during the initial kitchen tour of the annual survey. At 10:30 AM, the surveyor observed steam escaping from both ends of the high temperature conveyor dish machine and scattering throughout the dish machine room. The surveyor also observed excessive buildup of black substances on the surfaces and open seams of the two vent stacks, along with significant buildup of black substances along the edges of the dropdown ceiling tiles and the drywalls in the mechanical dish room.
Missed Required Attending Provider Visits
Penalty
Summary
Facility staff failed to ensure that Resident #5 was seen face-to-face by an attending provider at least every 60 days. A medical record review showed provider visit notes on 3/4/25, 3/5/25, 3/10/25, 3/12/25, 3/31/25, 4/1/25, 4/8/25, 4/11/25, 4/21/25, 4/28/25, and 6/18/25, but no documented attending provider visits from August 2025 until the next visit on 12/1/25, leaving a 166-day gap between visits. During interviews, the director of clinical operations stated residents must be seen by an attending provider at least every 60 days after admission, and the attending provider stated visits were alternated between him and a NP and sometimes recorded in the physical chart. A follow-up review of the resident’s physical chart still showed no evidence of provider visits during the August-to-December 2025 period, and the provider confirmed the chart lacked documentation for that time.
Delayed Review of Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that attending physicians reviewed and acted on pharmacist-identified irregularities in a timely manner for one resident who had been receiving multiple medications, including duloxetine for depression. Monthly medication review notes showed that on 8/8/25 the pharmacist recommended documenting the need for duloxetine 60 mg daily and considering a gradual dose reduction to 40 mg daily if appropriate. The resident had been in the facility since 2019 and remained on the antidepressant during the period reviewed. The attending provider did not sign the 8/8/25 pharmacy recommendation until 10/29/25, 82 days after it was made, and responded by reducing the antidepressant from 60 mg to 30 mg daily. The DON stated that pharmacy recommendations were usually faxed to the provider’s office and flagged in the resident’s hard chart, and confirmed that this recommendation had not been addressed for two months even though subsequent monthly medication reviews were completed on 9/17/25 and 10/9/25 before the 8/8/25 recommendation was acted on.
Nonfunctional kitchen equipment observed during survey
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper operating condition, as observed during the annual survey for 2 of 2 pieces of equipment reviewed. During an initial kitchen tour with staff, a sign was posted on a nonfunctional hand sink located by the food preparation area stating that the faucet had not been working since 3/18/2026. Staff confirmed that a work order had been submitted for the sink. Later in the tour, the surveyor observed a Continental undercounter freezer turned off, and staff confirmed that the unit was nonfunctional and that a work order had been submitted.
Failure to Maintain Professional Standards in Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a survey of the main kitchen. The surveyor noted several instances of opened and unlabeled food items, including bags of carrots, lettuce, spinach, and chicken nuggets, as well as various containers of sauces and condiments. Additionally, there were uncovered items such as a large tub of apple cider, a pan of greens, and a tub of chicken stock. Expired items were also found, including a container of ginger garlic paste and a jar of capers. These observations were made in the produce refrigerator, meat/fish cooler, main freezer, and dry goods storage area. The surveyor confirmed these findings with the Certified Food Services Manager (CFSM) #4, who acknowledged the presence of opened, unlabeled, and expired foods. The facility's Food and Supply Storage policy requires that unused portions and open packages be covered, labeled, and dated, and that expired foods be discarded by their respective dates. The CFSM provided evidence of an in-service conducted with kitchen personnel to review proper labeling and dating procedures, although this action is not part of the deficiency itself.
Improper Use of Gait Belt as Restraint by Private Duty Aide
Penalty
Summary
The facility failed to maintain an environment free of physical restraints, as evidenced by an incident involving a resident's private duty aide (PDA) improperly using a gait belt as a restraint. The incident was identified when a nurse observed the PDA using the gait belt to prevent the resident from getting up out of their wheelchair. This action was contrary to the intended use of a gait belt, which is meant to assist with mobility and not to restrict movement. The facility conducted an investigation and substantiated the improper use of physical restraints by the PDA. Interviews with staff confirmed that there were no other instances of physical restraint use. The PDA was contracted by the resident's family, and the facility had policies in place that required PDAs to adhere to the facility's procedures, including those related to nursing care. The incident was one of four facility-reported incidents reviewed during the survey.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required 2-hour timeframe and did not submit the results of the investigation within 5 days to the Office of Health Care Quality. This deficiency was identified during a review of a facility reported incident involving a resident who was found with a swollen left leg and a bruise on the left shin during activities of daily living care. The Director of Nursing was informed of the incident shortly after it was discovered and initiated an investigation. The resident involved had a BIMS score of 2, indicating significant cognitive impairment, and was unable to provide information about the injury. The facility was unable to determine the cause or timing of the incident. The initial report to the Office of Health Care Quality was submitted approximately 24 hours after the incident was discovered, and the investigation results were submitted 6 days later, both outside the required reporting timeframes.
Failure to Provide Routine Dental Care
Penalty
Summary
Facility staff failed to ensure a resident received routine dental care, as evidenced by the case of a resident who was reviewed for dental services during the survey. The resident's medical record showed a progress note from November 2021 indicating an order for a dental evaluation due to a broken tooth. However, there was no documentation in the medical record to confirm that the resident received any dental services prior to the incident of the broken tooth. During an interview, the Nursing Home Administrator (NHA) stated that the facility does not provide routine dental services and that residents are informed to arrange their own dental care, with the facility only arranging appointments when a concern is identified.
Deficiencies in Medical Record Documentation and Beneficiary Notification
Penalty
Summary
The facility staff failed to ensure that a resident's medical record included all necessary documentation related to dental treatment. Specifically, for one resident, a progress note indicated an order for a dental evaluation due to a broken tooth. However, the documentation of the treatment plan following the dental visit was missing, even after the Power of Attorney was contacted. The Nursing Home Administrator (NHA) was unable to provide the required documentation when requested by the surveyor. Additionally, the facility did not correctly complete beneficiary notification documentation for two residents. One resident was discharged without receiving a Notice of Medicare Non-Coverage (NOMNC) due to a lack of notice about the discharge, and there was no documentation to support that the discharge was requested by the resident. For another resident, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) was incomplete, as the resident did not select one of the required options regarding Medicare and payment. The Director of Social Services acknowledged the oversight.
Failure to Maintain a Homelike Environment Due to Wall Damage
Penalty
Summary
The facility staff failed to maintain a homelike environment, as evidenced by damaged drywall behind residents' beds in three of the six rooms observed during a medication administration assessment. Specifically, the surveyor noted marring on the walls behind the beds of three residents. During the observations, both a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) confirmed the surveyor's findings. The LPN acknowledged that the resident's bed might have caused the damage, despite having a stopper. However, the LPN admitted not noticing the damage until it was pointed out by the surveyor. Additionally, the RN had been on vacation for two weeks prior to the survey and had not reported the damage before that day. The staff used a computer-generated app named Worxhub Links to report maintenance issues, but the damage had not been reported prior to the surveyor's observation.
Failure to Revise Care Plan for Resident's Communication Needs
Penalty
Summary
The facility failed to ensure that a resident-centered care plan was revised to meet the needs of a resident, specifically in response to current interventions related to communication and sensory needs. The deficiency was identified for a resident with diagnoses including dementia, anxiety, hearing deficit, and major depressive disorder. The resident had physician orders to use bilateral hearing aids and required visual cues for effective communication. However, the resident frequently refused to wear the hearing aids, citing discomfort and excessive noise, and this refusal was documented multiple times over several months. Despite an audiology visit that adjusted the hearing aids to a comfortable volume and provided updated recommendations for communication, the care plan was not revised to reflect these changes or the resident's refusal to wear the hearing aids. The care plan, initially created in October 2023 and revised in January 2024, did not include the resident's refusal to wear hearing aids or the updated communication strategies recommended by the audiologist. This oversight was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the resident's inconsistent use of hearing aids and the lack of updated documentation in the care plan.
Failure to Monitor Resident Weight Loss
Penalty
Summary
The facility failed to maintain professional standards of practice regarding the monitoring of resident weights, as evidenced by the cases of two residents. Resident #7 experienced a significant weight loss of 10.17% within approximately one month, dropping from 108.2 lbs to 97.2 lbs. The Registered Dietician (Staff #23) identified the weight loss and suspected a scale error, requesting a reweigh on 01/06/25, which was not conducted until 01/08/25. Despite recognizing the significant weight loss, there was no documentation of an order for weekly reweighs for four weeks, and Staff #23 did not report the delay in reweighing to her supervisor. Similarly, Resident #21 experienced a 6.99% weight loss within about a month, from 146.0 lbs to 135.8 lbs. The Registered Dietician noted the significant weight loss but faced difficulties in reweighing the resident and could not find documentation of a refusal to be reweighed. There was also no documentation of an order for weekly reweighs for four weeks. The Registered Nurse (Staff #5) indicated that significant weight differences should prompt immediate reweighing to confirm accuracy and that any refusal to be weighed should be documented, which was not evident in this case.
Deficiency in Dementia Training for LPN
Penalty
Summary
The facility staff failed to ensure that a Licensed Practical Nurse (LPN) working on the memory care unit had completed the necessary competency training to effectively care for residents with dementia. During the Medicare/Medicaid survey, it was found that the LPN's last documented dementia training had expired, and the training they completed did not provide detailed information on caring for residents with dementia. The Director of Human Resources confirmed that annual training assignments are given to staff, and a report is sent to supervisors to track completion. However, the training completed by the LPN only mentioned cognitive impairment without specific focus on dementia care, which is not equivalent to a diagnosis of dementia.
Failure to Update Staffing Sheets in LTC Facility
Penalty
Summary
The facility staff failed to update the staffing sheets on two units in the Long-Term Care Wing after changes were made to the staffing schedule. On the day of the survey, the surveyor reviewed the Daily Nursing Schedule log and found discrepancies in the staffing documentation. Specifically, on one unit, a Geriatric Nursing Assistant (GNA) was documented as working, but had called out, and this was not reflected on the staffing sheet. Additionally, two GNAs were called in to work that day, but their presence was not updated on the staffing sheets. The Director of Nursing acknowledged that sometimes staff call the scheduler directly when unable to work, and updates are supposed to be transcribed to the daily staffing sheet, which was not done in this instance.
Pharmacy Fails to Administer Prescribed Supplement Dosage
Penalty
Summary
The facility's pharmacy failed to administer a prescribed supplement with a dosage for Resident #19, who was observed during a medication administration survey. On February 14, 2025, at 9:41 AM, during the observation of Resident #19's medication administration, the surveyor noticed that the blister package containing Vitron C did not have a specified dose. The medication administration record (MAR) indicated that Vitron C 65-125 MG (Iron -Vitamin C) was to be administered by mouth twice a day for anemia. Licensed Practical Nurse #8, who was preparing the medications, acknowledged having previously called the pharmacy to verify the dose. On February 18, 2025, the surveyor interviewed Pharmacist #17, who confirmed that the pharmacy typically does not send medications or supplements without a dose. Later, Pharmacist #12 explained that it was not feasible to list all ingredients in a supplement and that the dose might be written on the MAR, but the medication only comes in one form. Pharmacist #12 also stated that the pharmacy would be willing to add the strength of the supplement or medication if needed.
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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