Larkin Chase Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bowie, Maryland.
- Location
- 15005 Health Center Drive, Bowie, Maryland 20716
- CMS Provider Number
- 215264
- Inspections on file
- 15
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 18 (2 serious)
Citation history
Health deficiencies cited at Larkin Chase Center during CMS and state inspections, most recent first.
A resident with multiple cardiac and neurologic comorbidities developed acute respiratory distress, prompting an NP to order STAT labs and a chest x-ray to evaluate for pneumonia and other causes of clinical decline. The lab vendor later reported critical and abnormal results, including severe hypernatremia and markedly elevated WBC, to evening nursing staff, but the provider was not notified at that time despite facility policy requiring immediate physician notification for significant changes and critical values. The NP did not review the STAT lab results until the next day, at which point IV fluids were started and the attending physician was consulted, leading to an order to transfer the resident to the ED. EMS found the resident hypotensive with agonal respirations, and despite CPR in the hospital, the resident was pronounced dead. Surveyors cited Immediate Jeopardy under F580 for failure to promptly notify the provider of critical lab values after a change in condition.
A resident with multiple cardiac and neurologic comorbidities developed acute respiratory distress, prompting an NP to order a STAT chest x-ray and STAT labs (CMP, magnesium, CBC with differential) to rule out pneumonia and other causes. The STAT chest x-ray was never completed, and although the lab vendor obtained blood and later phoned in critical results including severe hypernatremia, elevated BUN, high magnesium, and markedly elevated WBC, the provider was not notified that evening. The NP was unaware the x-ray had not been done and that critical labs had been reported, and stated she would have sent the resident to the hospital if notified. The DON, Medical Director, and Administrator all described expectations for immediate provider notification of changes in condition, critical labs, and unfulfilled orders, but these expectations were not met in this case, leading to an F684 Immediate Jeopardy citation for failure to provide appropriate and timely care according to orders and resident condition.
Surveyors found that the facility failed to timely obtain, transcribe, and implement wound care orders for two residents with in-house acquired pressure ulcers, and did not consistently assess or document these wounds. One resident developed a Stage 2 pressure ulcer on the posterior lower leg that was identified and measured by the skin team, but no wound care order was entered until nearly two weeks later, just before discharge. Another resident with hemiplegia had moisture-associated skin damage and a sacral wound for which a wound physician ordered specific treatment that was never transcribed to the order recap or TAR, and nursing documentation repeatedly conflicted with the physician’s Stage 3 pressure ulcer staging and measurements. For this second resident, wound treatment orders lapsed and changed over time without clear continuity, the emergency contact was not informed of the wound until much later, and the RD was never notified of the new pressure ulcer despite facility policy requiring IDT notification and coordinated wound treatment.
The facility failed to obtain informed consent before administering psychotropic medications to two residents. One resident with anxiety and insomnia, who was cognitively intact per BIMS, received daily clonazepam for anxiety, and another resident with major depressive disorder and insomnia, with moderate cognitive impairment, received escitalopram via G‑tube for depression. In both cases, care plans identified risk related to psychotropic drug use, orders and MARs showed the medications were administered as prescribed, but the psychotropic medication disclosure/consent forms in their records were blank. Nursing staff, the DON, and the Administrator all acknowledged that psychotropic medications require consent prior to use under federal guidelines.
The facility failed to follow its abuse reporting policy when an allegation of sexual abuse involving a resident with muscle weakness and intact cognition was not reported to the state survey agency within the required two-hour timeframe. Policy required immediate entry of abuse allegations into the PCC risk management system and reporting of abuse, including sexual abuse, within two hours of the allegation. The DON informed the Administrator of the allegation after a housekeeper reported seeing another housekeeper hug and kiss the resident, but the incident was not reported to the state agency until more than two hours later, contrary to facility policy and the Administrator’s stated expectation for immediate reporting.
The facility failed to follow its abuse prohibition policy by not interviewing the CNAs assigned to a resident after the resident, who had muscle weakness and intact cognition, alleged neglect and rough care during the night shift. Although the resident reported being left in bed without a bath or assistance, experiencing rough care from a female aide, and having the call light turned off, the investigation only included statements from two RNs and one CNA who was not among the staff assigned during the reported shifts. Staffing records showed specific CNAs were assigned to the resident during the timeframe of the alleged incident, but these primary care staff were not interviewed, despite the DON’s acknowledgment that such interviews are typically part of an abuse investigation.
The facility failed to accurately code the MDS for a resident with documented Stage 3 pressure ulcers. Although the resident had a history of hemiplegia with moderate cognitive impairment and was care planned as at risk for skin breakdown with existing pressure ulcers on the sacral/right gluteal area, left heel, and left lateral ankle, the quarterly MDS indicated no risk for pressure ulcers and no unhealed pressure ulcers. Progress notes from a wound physician and an evening nursing supervisor documented unhealed and in-house acquired Stage 3 pressure ulcers on the sacrum and left gluteus during the MDS look-back period. In interviews, the DON confirmed the ulcers should have been coded, the MDS Coordinator admitted she missed coding the Stage 3 ulcer, and the Administrator stated he would expect a Stage 3 pressure ulcer to be reflected on the MDS.
Staff failed to protect resident PHI when an LPN left an EHR screen visible on a hallway medication cart during medication administration. The cart was positioned between resident rooms for several minutes with the EHR open and displaying information for multiple residents while visitors and staff walked past. The LPN later locked the cart but did not close or conceal the EHR, and subsequently acknowledged leaving resident information visible. The DON reported that staff are expected to protect residents’ personal health information and ensure EHR screens are not visible to passersby.
A medication cart was observed unlocked and unattended in a hallway between resident rooms while visitors and staff passed by. Facility policy required that only authorized staff access medication carts and that carts remain locked when not in use or not attended by authorized personnel. An LPN later returned to the cart, locked it, and admitted leaving it unlocked and unattended despite knowing it should be locked when not in direct line of sight. The DON confirmed that nurses are expected to keep medication carts locked when not directly observing them.
Failure to Notify Provider of Critical Lab Results Following Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a provider of critical and abnormal laboratory values for one resident who was being evaluated for a change in condition. The resident had a history of atherosclerotic heart disease, paroxysmal atrial fibrillation, encephalopathy, vascular dementia, traumatic subdural hemorrhage, hypertension, and cognitive communication deficit, and had a BIMS score of 11 indicating moderate cognitive impairment. On the day of the incident, a nurse practitioner (NP) was requested to evaluate the resident for acute respiratory distress, noting difficulty breathing with use of accessory muscles, lung crackles, and oxygen saturation of 93–96% on room air. In response, the NP ordered STAT laboratory tests, including a comprehensive metabolic panel, magnesium level, and CBC with differential, as well as a STAT chest x-ray, to rule out pneumonia and assess for other underlying causes of the resident’s clinical decline. The laboratory vendor received the STAT lab order late that morning, collected the blood specimen in the afternoon, and later that evening reported the results to the facility. The lab results showed a critically high sodium level of 161 mmol/L, elevated BUN of 55 mg/dL, elevated magnesium of 2.9 mg/dL, and a markedly elevated WBC count of 29.68 x10^3/uL. The laboratory vendor representative stated that the critical and abnormal values were reported by phone to the Evening Nursing Supervisor at 8:57 PM. The Evening Nursing Supervisor acknowledged recalling a call about the resident’s critical and abnormal lab values but stated she did not think she was the person the lab had called. Despite the facility’s policy requiring immediate notification of the physician and resident representative when there is a significant change in condition or clinical complication, the provider was not informed of these critical results on the evening they were received. The NP later documented, on the following day, that the STAT lab results obtained the prior day were reviewed at that time and showed significant abnormalities, including severe hypernatremia, elevated BUN consistent with acute kidney injury, and markedly elevated WBC concerning for dehydration, possible infection, and renal impairment. After this delayed review, the resident was started on IV fluids and the NP discussed the resident’s condition and abnormal labs with the attending physician, who agreed the resident required transfer to the hospital for further evaluation and management at a higher level of care. Emergency medical services were called due to decreased oxygen saturation, and upon arrival at the hospital the resident was noted to be hypotensive with agonal respirations, progressed to pulselessness, underwent CPR, and was pronounced dead. The surveyors determined that the facility’s noncompliance with the requirement to immediately inform the physician of significant changes and critical lab values caused, or was likely to cause, serious injury, harm, impairment, or death, and cited Immediate Jeopardy under F580, Notification of Changes.
Failure to Complete STAT Diagnostics and Notify Provider of Critical Labs After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a STAT chest x-ray was completed as ordered and to promptly notify a provider of critical and abnormal laboratory values for a resident who experienced a change in condition. The resident had a medical history including atherosclerotic heart disease, paroxysmal atrial fibrillation, encephalopathy, vascular dementia, traumatic subdural hemorrhage, hypertension, and cognitive communication deficit, and had a BIMS score of 11 indicating moderate cognitive impairment. On the day of the change in condition, a nurse practitioner (NP) was requested to evaluate the resident for acute respiratory distress and documented that the resident had difficulty breathing with use of accessory muscles, lung crackles, and oxygen saturation of 93–96% on room air. In response, the NP ordered a STAT chest x-ray and STAT laboratory tests, including a CMP, magnesium level, and CBC with differential, to rule out pneumonia and assess for other possible underlying causes. Physician orders were entered for the STAT chest x-ray and STAT laboratory tests within minutes of the NP’s assessment. The medical record, however, contained no evidence that the STAT chest x-ray ordered that day was ever completed. The x-ray vendor later reported receiving an x-ray order on a subsequent day and stated that when the technician arrived, the resident had already been sent to the emergency room, and that no STAT chest x-ray order had been received on the earlier date when the NP initially ordered it. The DON stated there was no written policy providing guidance on STAT orders, but there was a mutual expectation that STAT orders should be completed within four hours, and the x-ray vendor representative stated the vendor had eight hours to complete a STAT x-ray. The laboratory vendor reported receiving the STAT lab order late that morning, collecting the blood specimen in the afternoon, and communicating the critical and abnormal results to the Evening Nursing Supervisor later that evening. The lab results showed a critically high sodium level of 161 mmol/L, elevated BUN of 55 mg/dL, elevated magnesium of 2.9 mg/dL, and a markedly elevated WBC count of 29.68 x10^3/µL. The Evening Nursing Supervisor recalled receiving a call about the critical and abnormal lab values but stated she did not think she was the person the lab had called. The NP stated she was not aware the chest x-ray had not been completed and that the facility should have contacted the provider when the critical lab results were received; she further stated that had she been notified that evening, she would have sent the resident to the hospital. The DON confirmed that nurses were responsible for following up on STAT orders, notifying the provider if labs or x-rays were not completed, and reporting all critical lab values immediately, and acknowledged she was unaware that the resident’s critical lab results had not been reported to the provider. The Medical Director and Administrator both stated their expectation that providers be notified immediately of any change in condition, all critical lab results, or if an order could not be carried out. The resident was ultimately transferred to the hospital the following day after the NP reviewed the lab results and clinical status and obtained an order for transfer due to critical lab values and elevated WBC count. Upon arrival at the hospital, the resident was noted by EMS and emergency department documentation to be hypotensive with agonal respirations. EMS initiated intraosseous access, fluids, and bagging, and the resident lost pulses, prompting CPR initiation. The emergency department record indicated the resident remained pulseless and in asystole despite multiple rounds of CPR and medications, and resuscitation efforts were terminated with a recorded time of death. The surveyors determined that the facility’s noncompliance with requirements for quality of care, specifically the failure to complete the ordered STAT chest x-ray and to promptly notify the provider of critical and abnormal laboratory values, caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F684, Quality of Care, at an Immediate Jeopardy level.
Failure to Implement and Coordinate Pressure Ulcer Care and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent new ulcers from developing for two residents. For one resident with a history of left femur fracture, right lower leg fracture, and orthopedic aftercare, the admission MDS showed intact cognition and no unhealed pressure ulcers, though the resident was at risk for pressure injury due to decreased mobility. A care plan focus area was initiated for risk of skin breakdown. On 03/06/2026, the Skin Health Team Lead (SHTL) documented a newly identified in-house acquired Stage 2 pressure ulcer on the resident’s right posterior lower leg, measuring 8.93 cm by 5.43 cm, which later increased in size by 03/12/2026. Despite this, there was no corresponding wound care order in the medical record until 03/18/2026, with treatment starting 03/19/2026, one day before discharge home. The SHTL stated wound care was performed daily but confirmed that wound care orders were not implemented until 03/18/2026 and could not explain the lack of earlier orders. For the second resident, admitted with hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, the quarterly MDS indicated moderate cognitive impairment and no unhealed pressure ulcers, and not at risk for pressure ulcers, although the care plan documented risk for skin breakdown related to incontinence, limited mobility, and a pressure ulcer on the right gluteus/sacral area, left heel, and left lateral ankle. The care plan directed weekly wound assessments with measurements and descriptions. On 01/06/2026, an eINTERACT SBAR note by the Evening Nursing Supervisor documented moisture-associated skin damage (MASD) on the left gluteal area and a wound physician’s order to cleanse with wound cleanser, pat dry, apply medical honey plus calcium alginate, and cover with a dry dressing. However, there was no evidence on the Order Recap Report or the TAR that this order was transcribed or implemented. Subsequent Skin Issues notes and wound physician progress notes showed inconsistent characterization and staging of the resident’s sacral/left gluteal wound, with nursing documentation describing MASD and unstageable pressure ulcers with varying measurements, while the wound physician consistently documented a Stage 3 pressure ulcer with different measurements and noted the wound as deteriorating at one point. The facility’s documentation for the second resident also showed gaps and inconsistencies in wound treatment orders over time. An order dated 01/25/2026 directed daily cleansing of the left gluteal wound with wound cleanser, hydrogel, and gauze/foam dressing, but this order ended on 02/09/2026. A later order dated 03/26/2026 for sacral wound care with wound cleanser, plurogel, calcium alginate, and foam dressing every day and as needed was discontinued on 04/03/2026, and replaced with a one-time and every day shift order for cleansing and calcium alginate with foam dressing. The Lead Registered Dietician (RD) reported she was not familiar with this resident and, upon review of the record, stated it did not appear that any new nutritional orders were implemented when the wounds developed and that she would have expected to be notified of the new wounds. The resident’s emergency contact stated they were unaware of the sacral wound since January and believed the wound had just developed based on a recent call. The DON acknowledged that skin meetings did not include a deep dive into whether wound orders were appropriate or implemented, could not explain why the staff did not document the pressure ulcer as Stage 3 as the wound physician did, and could not state why orders to treat the pressure ulcer were missed, while the Administrator stated that residents’ wounds must be monitored and documented appropriately. The facility’s own policy, NSG236 Skin Integrity and Wound Management, required notification of interdisciplinary team members for a comprehensive approach to care, including prevention and wound treatments, and implementation of special wound care treatments and techniques as indicated and ordered. In both residents’ cases, the survey findings showed failures to ensure timely and appropriate wound care orders were obtained, transcribed, and implemented after in-house acquired pressure ulcers were identified, failures to notify the Lead RD of new pressure ulcers, and inconsistencies in assessment and documentation of the pressure ulcer’s stage and characteristics. These actions and inactions directly conflicted with the facility’s stated policy requirements.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications to two residents. For one resident with anxiety disorder and primary insomnia, the admission MDS showed a BIMS score of 15, indicating intact cognition, and documented antianxiety medication use. The resident’s care plan, initiated shortly after admission, identified risk for complications related to psychotropic drugs and included an intervention to provide informed consent to the resident or healthcare decision maker. Physician orders and MARs showed clonazepam 0.5 mg was ordered and administered daily for anxiety over a two‑month period. However, the Psychotropic Medication Administration Disclosure form in the resident’s medical record was blank. Nursing staff interviewed acknowledged that psychotropic medications required consent prior to use and could not recall reviewing the psychotropic consent with the resident, and facility leadership confirmed that consent had not been obtained. For a second resident with major depressive disorder and primary insomnia, a quarterly MDS documented moderate cognitive impairment with a BIMS score of 11 and antidepressant use. The resident’s care plan, initiated after admission and later revised, also identified risk for complications related to psychotropic drugs. The Order Recap Report showed an order for escitalopram 20 mg via gastrostomy tube at bedtime for depression, and the MAR confirmed the medication was administered as ordered. As with the first resident, the Psychotropic Medication Administration Disclosure form in this resident’s record was blank. During interviews, the DON confirmed that consent for psychotropic medications had not been obtained when the medication was started, and the Administrator stated that psychotropic medications required consent prior to use according to federal guidelines.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse to the state survey agency for one resident. Facility policy titled “Abuse Prohibition,” revised 11/14/2025, required that upon receiving information about suspected or alleged abuse, the Administrator or designee must enter the allegation into the PCC Risk Management Portal and report allegations involving abuse, including sexual abuse, no later than two hours after the allegation is made. Resident #5, admitted on 12/04/2025, had a medical history including muscle weakness and a quarterly MDS with an ARD of 02/09/2026 showing a BIMS score of 13, indicating intact cognition. On 03/19/2026 at 9:30 AM, the DON notified the Administrator of an allegation of sexual abuse involving Resident #5, after Housekeeper #2 reported seeing Housekeeper #1 enter the resident’s room and hug and kiss the resident. The Facility Reported Incident Initial Report Form documented that this allegation was reported to the state survey agency at 12:13 PM, which exceeded the facility’s policy requirement to report such allegations within two hours. During an interview, the Administrator stated his expectation was that any allegation of abuse must be reported immediately. This sequence of events, including the time the allegation was received and the time it was reported to the state survey agency, demonstrated that the facility did not adhere to its own policy for timely reporting of abuse allegations.
Failure to Interview Assigned Staff After Resident’s Allegation of Neglect
Penalty
Summary
The facility failed to ensure that staff assigned to care for a resident were interviewed after the resident voiced an allegation of neglect. Facility policy "OPS300 Abuse Prohibition" required that an investigation be initiated within 24 hours of an allegation of abuse, focusing on whether abuse or neglect occurred, causative factors, and interventions to prevent further injury, and that the investigation be thoroughly documented with witnessed interviews. Resident #1, who had a diagnosis of muscle weakness and an intact cognition as evidenced by a BIMS score of 15 on a quarterly MDS, reported on two occasions that they were left in bed without a bath or assistance, that a female GNA was rough when providing care, and that their call light was turned off during the 11:00 PM to 7:00 AM shift. The facility’s investigation file contained statements from two RNs and one GNA (GNA #5), but did not include interviews with the GNAs who were actually assigned to the resident during the relevant shifts. Staffing assignments showed that GNA #10 was assigned to the resident on two consecutive nights during the 11:00 PM to 7:00 AM shift, and GNA #13 was assigned on the following night during the same shift, which matched the timeframe identified by the resident. During interviews, the resident confirmed the incident occurred on the night shift but could not recall the employee’s name. The DON stated that during an investigation the facility typically interviewed the primary care staff assigned to the resident at a minimum, and the Administrator stated that abuse investigations should be thoroughly investigated to determine the thoroughness of the investigation, underscoring that the assigned staff were not interviewed as required by policy.
Inaccurate MDS Coding for Resident With Stage 3 Pressure Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident with pressure ulcers/injuries. The quarterly MDS with an Assessment Reference Date of 02/17/2026 documented that the resident was not at risk for developing pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. This coding was completed despite existing documentation in the resident’s medical record and care plan indicating the presence of pressure ulcers. The facility reported that it followed the CMS LTC Facility RAI 3.0 User’s Manual for MDS completion, which requires coding of any pressure ulcer/injury present during the 7‑day look‑back period. The resident, admitted on 08/05/2025, had a medical history including hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left non-dominant side and had a BIMS score of 10, indicating moderate cognitive impairment. The resident’s care plan, initiated on 08/07/2025, identified them as at risk for skin breakdown related to incontinence, limited mobility, and existing pressure ulcers on the right gluteus/sacral area, left heel, and left lateral ankle. Progress notes dated 01/28/2026 by the wound physician documented an unhealed Stage 3 pressure ulcer on the sacrum, and notes dated 02/12/2026 by the evening nursing supervisor documented an in-house acquired Stage 3 pressure ulcer on the left gluteus. During interviews, the DON confirmed the pressure ulcer should have been coded on the MDS, and the MDS Coordinator acknowledged she missed coding the Stage 3 pressure ulcer, while the Administrator stated that a Stage 3 pressure ulcer should be reflected on the MDS.
Failure to Protect Resident PHI on Medication Cart EHR Screen
Penalty
Summary
The facility failed to protect residents’ private and confidential information during medication administration when an electronic health record (EHR) was left visible on a medication cart in a hallway. On 2/19/26, a medication cart was observed positioned between specified resident rooms from 9:55 a.m. to 9:59 a.m., with the EHR screen displaying resident information for 14 of 73 residents. During this time, several visitors and staff members walked past the cart in the hallway while the EHR remained open and visible. The LPN responsible for the cart exited a resident room, approached the cart, and locked it but did not close or obscure the EHR screen containing resident information. In an interview immediately afterward, the LPN acknowledged being responsible for the cart and confirmed that the EHR with resident information had been left visible. In a separate interview, the DON stated that the facility’s expectation is that nursing staff protect residents’ personal health information and ensure the EHR is not visible to passersby. No additional resident-specific medical histories or clinical conditions related to the affected residents were provided in the report.
Unattended Unlocked Medication Cart Left Accessible in Hallway
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments when not in use, as required by facility policy and professional standards. The written policy on medication storage stated that only licensed nurses, pharmacy staff, and other authorized personnel may access medication carts, and that medication rooms, cabinets, and supplies must remain locked when not in use or attended by authorized staff. During observation, a medication cart was seen positioned between resident rooms, unlocked and unattended for approximately four minutes while several visitors and staff walked past it in the hallway. The LPN responsible for the cart later returned, locked the cart, and acknowledged having left it unlocked and unattended despite knowing it should be locked when not in direct line of sight. The DON confirmed that the facility’s expectation is that nurses keep medication carts locked when they are not directly observing them. No specific residents, their medical histories, or conditions at the time of the deficiency were identified in the report, and the deficiency centered on the unsecured medication cart and staff noncompliance with the established medication storage policy.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
