Montcare At Potomac
Inspection history, citations, penalties and survey trends for this long-term care facility in Potomac, Maryland.
- Location
- 10714 Potomac Tennis Lane, Potomac, Maryland 20854
- CMS Provider Number
- 215171
- Inspections on file
- 18
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Montcare At Potomac during CMS and state inspections, most recent first.
Inaccurate MDS coding was found for two residents. One resident with vascular dementia and depression was receiving Abilify daily, but the MDS incorrectly showed no antipsychotic use in the prior 7 days. Another resident with severe cognitive impairment, documented elopement risk, and an alert bracelet was observed pacing, yet the MDS incorrectly coded the wander/elopement alarm as not used.
A resident had a nebulizer machine with unlabeled tubing observed on the nightstand, while the chart showed orders for weekly mask and tubing changes and PRN Ipratropium-Albuterol via nebulizer for SOB/emphysema. Review of the care plan found no evidence that a care plan had been initiated to address nebulizer treatment, and the DON acknowledged the finding.
Care plans were not revised to match current resident needs for three residents. One resident’s diuretic therapy had been discontinued, but the care plan still remained active. Two other residents had care plans that did not reflect observed nail care and personal hygiene needs, including long fingernails and dependence for personal hygiene, and the revisions were made only after surveyor intervention.
Failure to provide personal hygiene for dependent residents was identified when two residents with intact cognition and MDS-documented dependence for personal hygiene were observed with overgrown fingernails. One resident had long fingernails, and another reported repeated notifications to staff about untrimmed nails, which were observed extending about half an inch beyond the fingertips. A follow-up observation confirmed both residents still had overgrown fingernails, and a GNA stated staff were expected to provide ADL care, including nail trimming.
Respiratory care was not provided consistently with orders and facility protocol for three residents. An LPN and Unit Manager found oxygen tubing, humidifier bottles, nebulizer tubing, and suction catheter left unlabeled or undated, and one resident’s record lacked an order for weekly oxygen equipment changes even though staff said that was the facility practice. Another resident had oxygen in use with an undated nasal cannula and a humidifier bottle dated earlier than the review, while active orders later confirmed weekly nebulizer equipment changes for a third resident.
A resident with recent falls and facial bruising was found to still be receiving Gabapentin 100 mg BID even after the attending MD ordered it decreased to 100 mg QD following a pharmacy review. The Unit Mgr confirmed the order had not been implemented, and the DON was notified.
Unlabeled Opened Insulin Pens: During a medication cart observation, two opened insulin pens for a resident were found without the required opened date label. An RN unit manager confirmed the pens were opened and unlabeled, and the DON stated opened insulin pens are expected to be labeled with the opened date. Facility policy required insulin pens to be labeled with the resident name and date opened.
In the laundry room, an employee removed clean linen from a dryer and placed it in a bin, then picked up a blanket that had fallen on the floor and put it back into the bin with the clean linen. When questioned, the employee acknowledged the action was not appropriate, and the supervisor was informed of the observation.
A facility failed to report a possible misappropriation of a resident's medication within the required 24-hour timeframe to the OHCQ. The incident involved missing Ativan tablets, and the delay in reporting was due to waiting for a pharmacy review. The DON confirmed the report was sent five days late.
A resident was observed unable to reach their call bell device, which was found draped over their wheelchair and behind a pillow, out of reach. The Unit Manager confirmed the device was not accessible and acknowledged the expectation for it to be within reach. The resident's care plan included an intervention to reinforce the need to call for assistance.
A facility failed to ensure a physician documented a resident's discharge in the medical record. An LPN noted the discharge and completed a form, but no physician documentation was found. The attending physician acknowledged the requirement to document within 30 days, but this was not done. The DON confirmed the absence of documentation.
A resident did not receive a recommended follow-up urology appointment after hospitalization for a cystoscopy with stent placement. The hospital discharge summary indicated the need for this follow-up, but no documentation was found in the medical record to show that the appointment was scheduled. The resident was later hospitalized again with a complicated UTI, suspected to be related to the stent. Facility staff confirmed the absence of any scheduled follow-up appointments.
A resident experienced a significant weight gain of 16% over 19 days, increasing from 80 to 93.4 pounds, without proper monitoring or physician notification. Despite facility policy requiring communication for significant weight changes, there was no documentation of communication between nursing staff, the dietitian, the physician, or the resident's family. The DON confirmed the oversight, acknowledging the facility's failure to adhere to its weight monitoring parameters.
A resident with chronic pain syndrome and severe cognitive impairment experienced inconsistent pain management at the facility. Despite orders to document pain scores every shift, pain medication was administered without clear parameters corresponding to these scores. Interviews and record reviews revealed frequent pain episodes and grimacing during care, highlighting the facility's failure to manage the resident's pain effectively.
A resident received unnecessary PRN pain medication when Tramadol was administered outside the prescribed parameters for moderate pain. The medication was given for pain scores of 0 and 2, contrary to the physician's order for moderate pain (score 4-6). The DON confirmed the inappropriate administration and noted that nurses sometimes gave medication based on resident requests without following orders.
A survey revealed deficiencies in medication storage and disposal of expired supplies in an LTC facility. A resident's medication was found on the floor, and expired medications and unsterile dressing supplies were discovered in medication and treatment carts.
A facility failed to document education on the benefits and side effects of influenza and pneumococcal vaccines for a resident who repeatedly refused them. Despite claims of annual and quarterly educational efforts by staff, no evidence was found in the resident's medical records. The DON acknowledged the deficiency when informed by the surveyor.
The facility failed to provide written notification to two residents and their representatives regarding the reason for their transfer to a hospital. One resident was sent to the ER for shortness of breath, weakness, and hypotension, while another was transferred to an acute care facility. In both cases, the reasons for transfer were communicated verbally but not documented in writing, as confirmed by staff and the Administrator.
A resident with a stage 4 sacrum pressure injury had incomplete medical records regarding wound care management. Despite physician's orders for daily care, documentation was missing on several dates in August and September. The DON confirmed these findings during a survey.
Inaccurate MDS Coding for Antipsychotic Use and Wander/Elopement Alarm Status
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents, including coding related to antipsychotic medication use and wander/elopement alarm status. Resident #108 had diagnoses of vascular dementia and depression. Review of quarterly MDS assessments with ARDs of 09/30/25 and 12/30/25 showed Section N0415 was coded as not receiving an antipsychotic medication in the last 7 days, even though the resident had a physician order dated 03/19/25 for Aripiprazole (Abilify) daily at bedtime and the MAR showed the medication had been administered daily since that date. The MDS Coordinator reviewed the record and confirmed the medication was an antipsychotic and that the MDSs were inaccurately coded. Resident #154 was observed pacing in the hallways and was confirmed by the RN/UM to be at risk for elopement and wearing an alert bracelet. The resident had a BIMS score of 4.0 indicating severe cognitive impairment, a Quarterly Risk Evaluation confirming elopement risk, a physician order for an alert bracelet with function checks every shift, and a care plan identifying the resident as an elopement risk/wanderer with a history of attempts to leave the facility unattended and removing the bracelet. However, the Annual MDS with ARD 10/14/25 coded Section P0200, item E (Wander/elopement alarm) as not used, despite staff verification that it should have been coded as used daily.
Incomplete Care Plan for Nebulizer Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for the use of a nebulizer for Resident #1. During the initial tour, a nebulizer machine with unlabeled tubing was observed on the resident’s nightstand. Review of the active physician orders showed orders for nebulizer mask and tubing changes weekly on night shift, as well as an order for Ipratropium-Albuterol inhalation solution to be given via nebulizer every 6 hours as needed for shortness of breath/emphysema. However, review of the care plan found no evidence that a care plan had been initiated to address nebulizer treatment. The DON confirmed that care plans were generated upon admission and updated by the Unit Manager or MDS Coordinator and acknowledged the survey findings and concerns.
Care plans were not updated to reflect residents’ current medication and ADL needs
Penalty
Summary
The facility failed to review and revise care plans to match residents’ current needs for 3 of 41 residents reviewed during the recertification survey. One resident was prescribed Triamterene-HCTZ for hypertension starting on 10/17/24 and received it until it was discontinued on 12/24/24, but the active care plan still addressed diuretic therapy and was not revised to reflect that the medication had been stopped. During interview, the Unit Manager confirmed the medication had been discontinued while the related care plan remained active, and the surveyor observed that the care plan was resolved only after surveyor intervention. Two other residents had care plans that did not reflect their current ADL needs related to nail care and personal hygiene. One resident was observed with long fingernails and had an MDS showing dependence for personal hygiene, while another resident expressed frustration about untrimmed fingernails and was observed with fingernails extending about half an inch beyond the fingertips; that resident’s MDS also showed impairment in upper and lower extremities and dependence for personal hygiene. Their care plans were revised only after surveyor intervention to include resistance to care, encouragement for ADL care, and nail care needs.
Failure to Provide Personal Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene to dependent residents, as shown by two residents who were reviewed for ADLs during the recertification survey. Resident #111 was observed with long fingernails and had a BIMS score of 15, indicating intact cognition. The resident’s quarterly MDS showed no impairment in range of motion but identified the resident as dependent for personal hygiene, meaning staff were responsible for completing the activity. Resident #91 also had overgrown fingernails, extending approximately half an inch beyond the fingertips, and expressed frustration that staff had been notified multiple times about the issue. This resident also had a BIMS score of 15 and a quarterly MDS showing impairment in the upper and lower extremities with a functional status of dependent for personal hygiene. A follow-up observation confirmed that both residents still had overgrown fingernails, and a GNA stated that staff were expected to provide ADL care, including nail trimming, and notify the assigned nurse if a resident refused.
Respiratory equipment was left unlabeled and orders were incomplete for oxygen and nebulizer care
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards for three residents reviewed for respiratory care. Resident #28 was observed receiving oxygen at 2 liters per minute via nasal cannula, but the oxygen tubing and humidifier bottle were not labeled to show when they had been changed. The resident’s record included orders for continuous oxygen at 2 liters per minute and for oxygen tubing, respiratory bag, and humidified water to be changed and dated weekly, yet staff confirmed the tubing and humidifier bottle in the room were unlabeled and could not state when they had been changed. Resident #4 was observed in bed using oxygen at 2 liters per minute via nasal cannula, with a humidifier bottle dated 02/01/26 and an undated nasal cannula. The resident’s record showed an order for oxygen as needed for pulse oximetry below 92%, but there was no order in the clinical record for changing the oxygen tubing and humidifier bottle at the time of review. Staff stated it was the facility practice to change and document these items weekly in the TAR, and the Unit Manager confirmed the order was missing from the record. Resident #1 was observed with unlabeled nebulizer machine tubing and suction catheter on the nightstand, and the active physician orders later confirmed nebulizer mask and tubing were to be changed weekly, while the facility’s nebulizer policy also required weekly tubing changes.
Physician’s Gabapentin Order Not Implemented
Penalty
Summary
The facility failed to ensure a resident received medication according to the physician’s orders. Resident #31 was observed sitting in a wheelchair at the nurse’s station with a bandage over the left eye and bluish discoloration with swelling on the face, and the resident stated, “I fell.” The clinical record showed the resident had fallen on one date and again on 02/08/26, after which the resident was transferred to the Emergency Room. The record also showed that the facility requested a pharmacy review because of the resident’s falls. On 02/09/26, the pharmacy consultant recommended decreasing Gabapentin. The resident had been receiving Gabapentin 100 mg twice daily since 01/11/26. On 02/11/26, the attending physician entered an order to decrease Gabapentin to 100 mg once daily, but the facility continued administering Gabapentin 100 mg twice daily. The Unit Manager reviewed the record and confirmed the order had not been implemented, and the DON was notified of the concern.
Unlabeled Opened Insulin Pens
Penalty
Summary
The facility failed to ensure opened insulin pens were labeled with the date opened in accordance with facility policy. During observation of a medication cart on the Medbridge Unit, two opened insulin pens for Resident #48 were found stored in the top drawer without an opened date documented on either pen. RN Unit Manager #6 confirmed that both pens were opened and did not have an opened date label, and the DON stated that opened insulin pens are expected to be labeled with the opened date. Review of the facility policy titled Insulin Pen, revised 1/31/24, showed that insulin pens must be labeled with the resident name and the date opened, and that if the label is missing, the pen will not be used and a new pen must be ordered.
Infection Control Lapse in Laundry Room
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices were followed in the laundry room. During observation, Staff #12 was seen removing clean linen from a dryer and placing it into a bin, and when a cream-colored blanket fell onto the floor, the staff member picked it up and placed it into the bin with the other clean linen. When the surveyor raised concern, Staff #12 acknowledged, "I am sorry, I should not do that." Supervisor Staff #13 later arrived, was informed of the finding, and Staff #12 confirmed the observation in the supervisor's presence.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility staff failed to report a possible misappropriation of resident property within the required 24-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). This deficiency was identified during a recertification/complaint survey for one resident among those reviewed for abuse. Specifically, the incident involved the disappearance of 28 tablets of Ativan 0.5 mg, which were supposed to be delivered to the facility. Although the controlled substance log was found on the staff's desk, the medication itself was missing. The Director of Nursing (DON) confirmed that the initial report of the incident was sent to OHCQ five days after the incident occurred, thus failing to meet the 24-hour reporting requirement. The delay was attributed to the facility waiting for the pharmacy to review the medications delivered on the day of the incident. The DON acknowledged the reporting delay but believed it was unnecessary to self-report while awaiting the pharmacy's review.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call bell device was within reach of a resident, leading to a deficiency. During an observation, a surveyor noted that a resident was lying in bed and gesturing, seemingly trying to communicate a need for assistance. Upon inquiry, the resident was observed searching for the call bell device, which was found to be plugged into the wall and draped over the resident's wheelchair, with the call device itself located behind a pillow on the wheelchair, out of the resident's reach. The Unit Manager confirmed the call bell was not accessible to the resident and acknowledged that the expectation was for residents to have their call bell within reach. The resident's care plan included an intervention to reinforce the need to call for assistance, highlighting the importance of having the call bell accessible.
Physician Discharge Documentation Deficiency
Penalty
Summary
The facility failed to ensure that a physician documented a resident's discharge in the medical record, as required. This deficiency was identified during a recertification/complaint survey for a resident who was discharged home. A progress note written by an LPN indicated the discharge, and a form titled 'My Transition Home' was completed by the LPN regarding the discharge. However, there was no documentation from the physician in the resident's medical record. The attending physician acknowledged that they should document discharges within 30 days, but upon review, no such documentation was found within the required timeframe. The Director of Nursing confirmed the absence of the physician's discharge documentation.
Failure to Schedule Follow-Up Urology Appointment
Penalty
Summary
The facility failed to ensure a resident received a recommended specialist follow-up appointment after hospitalization. The resident was discharged after a hospital stay where they underwent a cystoscopy with right ureteral stent placement. The hospital discharge summary indicated the need for a follow-up outpatient appointment with urology, as the stent was temporary and required further procedures. However, there was no documentation in the medical record indicating that the follow-up appointment was scheduled or attended. The deficiency was identified during a recertification/complaint survey, where it was found that the resident had been hospitalized again with a complicated urinary tract infection, which was suspected to be secondary to the ureteral stent. Interviews with facility staff, including the Unit Manager, Assistant Director of Nursing, and the Director of Nursing, confirmed the absence of any scheduled urology follow-up appointments. The attending physician acknowledged the lack of documentation regarding the recommended follow-up, and the facility staff could not provide evidence of attempts to schedule the necessary appointment.
Failure to Monitor and Communicate Significant Weight Gain
Penalty
Summary
The facility failed to adequately monitor and evaluate a resident's significant weight gain and did not notify the physician as required. A resident, who was receiving tube feedings upon admission, experienced a 16% weight gain over 19 days, increasing from 80 pounds to 93.4 pounds. Despite the facility's policy requiring physician notification for significant weight changes, there was no documentation of communication between nursing staff, the dietitian, the physician, or the resident's family regarding this weight gain. Interviews with staff revealed that weights were typically obtained by Geriatric Nursing Assistants and nurses, and significant changes were supposed to be communicated to the physician and dietitian. However, in this case, the process was not followed. The Director of Nursing confirmed the weight gain and acknowledged that the facility had parameters in place to notify the physician for weight changes of 3-5 pounds, which were not adhered to in this instance. The lack of weight tracking and communication contributed to the deficiency identified during the survey.
Inconsistent Pain Management for Resident with Chronic Pain Syndrome
Penalty
Summary
The facility failed to consistently evaluate and manage the pain of a resident receiving short-term rehabilitation, who was diagnosed with chronic pain syndrome and had severe cognitive impairment as indicated by a BIMS score of 0/15. Despite having an order to document pain scores every shift, the resident's pain management was inconsistent. Interviews with the resident's family member and staff revealed that the resident frequently experienced pain, grimacing during care, and that pain medication was administered without clear parameters corresponding to the documented pain scores. The resident's Medication Administration Record showed multiple instances where pain medication was given, but the administration did not align with the pain scores recorded. For example, oxyCODONE was administered for pain levels ranging from 3 to 6, but there were no specific guidelines for medication administration based on these scores. This inconsistency in pain management was confirmed during a review with the Director of Nursing, who acknowledged the lack of appropriate medication parameters corresponding to the resident's pain scores.
Inappropriate Administration of PRN Pain Medication
Penalty
Summary
The facility staff failed to adhere to physician orders by administering PRN pain medication outside the prescribed parameters, resulting in the resident receiving unnecessary medication. This deficiency was identified during a recertification/complaint survey for one of the five residents reviewed for unnecessary medications. The resident involved was admitted to the facility with multiple medical diagnoses, including disorders of muscle, infection due to cardiac valve, pneumonia, type 2 diabetes mellitus, presence of a cardiac pacemaker, and spondylosis lumbar region. The physician's order specified Tramadol HCL 25 mg to be given every 4 hours as needed for moderate pain, defined as a pain score of 4-6 on a scale of 0-10. Upon reviewing the resident's Medication Administration Record (MAR) for September 2024, it was found that Tramadol was administered on two occasions when the resident's pain score was below the prescribed threshold. Specifically, the medication was given for a pain score of 0 and 2, which did not meet the criteria for moderate pain as per the physician's order. The Director of Nursing confirmed the inappropriate administration of Tramadol and acknowledged that nurses sometimes administered medication based on resident requests without adhering to the prescribed parameters.
Medication Storage and Expired Supplies Deficiency
Penalty
Summary
During a recertification and complaint survey, it was observed that the facility staff failed to safely store a resident's medication and dispose of expired medications and dressing supplies. On the 2nd floor unit, a surveyor found a labeled plastic bag containing an Atenolol 50 mg tablet on the floor near a resident's bedside table. The medication was identified as belonging to the roommate of the resident in the room, although the Director of Nursing later confirmed that the resident was not currently prescribed Atenolol. The pharmacy associated with the facility did not recognize the packaging, suggesting it may have been brought in from the hospital with the resident's personal belongings. Additionally, on the 1st floor unit, expired medications and unsterile dressing supplies were found in the medication and treatment carts. A bottle of Pro-Stat protein supplement was found to be expired, and expired Iodoform Packing Strip and opened, unsterile Xeroform Petrolatum dressing were discovered in the treatment cart. These findings were confirmed by the registered nurses present during the observations, who immediately removed the expired and unsterile items from the carts.
Deficiency in Vaccine Education Documentation
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of the influenza and pneumococcal vaccines to Resident #29, as evidenced during a recertification/complaint survey. The medical record review revealed that Resident #29, who had been residing at the facility since March 2020, refused the influenza vaccine in 2020 and 2022, with no documentation for 2021 and 2023. There was no evidence in the resident's records to support that education on the vaccine's risks and benefits was provided. Similarly, the pneumococcal vaccine records showed refusals in 2020 and March 2024, again without documentation of educational efforts. Interviews with the Infection Control Preventionist (Staff #22) indicated that the facility claimed to provide annual influenza education and quarterly and yearly education for the pneumococcal vaccine to residents who refused. However, this was not documented in the Electronic Medical Record for Resident #29. The Director of Nursing (DON) acknowledged the concern when it was shared by the surveyor, validating the deficiency in providing necessary education to the resident.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and their representatives regarding the reason for transfer or discharge to a hospital. This deficiency was identified during a recertification/complaint survey for two residents who were hospitalized. Resident #136 was sent to the emergency room on 8/1/2024 for shortness of breath, weakness, and hypotension. Although the reason for transfer was documented in the change in condition form and verbally communicated to the resident and their representative, there was no written notification provided. The Licensed Practical Nurse confirmed that the reason for transfer was communicated verbally but not in writing. Similarly, Resident #70 was transferred to an acute care facility on 8/19/2024, and there was no documentation in the medical record indicating that the resident or their responsible party received written notice of the reason for the transfer. The Administrator acknowledged the absence of written documentation and confirmed the findings during the survey. The lack of written notification for both residents constitutes a failure to comply with regulatory requirements for resident transfer and discharge notifications.
Incomplete Medical Record for Wound Care Management
Penalty
Summary
The facility staff failed to maintain a complete and accurate medical record for a resident, as identified during a recertification/complaint survey. The resident, who had a stage 4 sacrum pressure injury, was discharged to acute care and later readmitted to the facility. Physician's orders dated April 20, 2024, specified daily wound care management for the pressure injury. However, the Electronic Medical Record and Treatment Administration Record lacked documentation of wound care management on several specified dates in August and September 2024. The Director of Nursing confirmed these findings during the survey.
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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