Regency Care Of Silver Spring, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 9101 Second Avenue, Silver Spring, Maryland 20910
- CMS Provider Number
- 215060
- Inspections on file
- 13
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Regency Care Of Silver Spring, Llc during CMS and state inspections, most recent first.
A resident with multiple serious conditions had an updated MOLST indicating DNR/DNI status after discussion with the attending physician and power of attorney, but staff did not void the prior full-code MOLST and failed to ensure the updated form was sent and clearly communicated to EMS during a change in condition, resulting in CPR and intubation contrary to the resident’s documented wishes. In a separate case, another resident had an order for Lisinopril with instructions to hold the dose only if systolic BP was below 100 mm Hg, yet an LPN withheld several doses when systolic readings were between 106 and 109 mm Hg, contrary to the physician’s specific parameters.
A resident with severe cognitive impairment, dysphagia, severe calorie malnutrition, dementia, and prostate cancer underwent a FEES swallowing evaluation after the SLP, following discussion with the responsible party, obtained physician orders for repeat testing to consider a diet upgrade. The FEES results, available the same day, recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids and specific compensatory strategies, including upright positioning, no straws, single sips, small bites, and slow intake, with possible use of a PROVALE cup. Review of the clinical record and an interview with the DON showed there was no nursing documentation that the physician had been notified of these FEES results, constituting a failure to immediately inform the physician of a significant change in swallowing assessment findings.
Facility staff failed to immediately report a suspected abuse incident to local law enforcement after a resident was found to have a fractured left humerus of unknown origin. The injury was reported to the State agency as an injury of unknown source, and a 5-day follow-up investigation documented that an x-ray confirmed the fracture, there were no witnesses, and the resident could not explain how the injury occurred. The resident’s BIMS score was recorded as 13/15, with noted fluctuation. Although facility policy assigns an Abuse Prevention Coordinator to report allegations or suspected abuse to the State Survey Agency and other officials per State law, the allegation was not reported to police, a fact later confirmed by the administrator and DON.
A resident with severe malnutrition, pharyngeal dysphagia, dementia, and other comorbidities had an existing nutritional risk care plan with goals and interventions related to diet tolerance and monitoring for dysphagia. After an SLP evaluation and a FEES exam, new recommendations were made for a soft and bite-sized/mechanical soft chopped diet with thin liquids and specific compensatory swallowing strategies, including upright positioning, no straws, single sips, small bites, and slow intake, with possible use of a Provale cup. Although these results were available to staff, the RN confirmed that the resident’s nutritional care plan was not updated with any new nursing interventions based on the FEES findings, resulting in a failure to revise the care plan to meet the resident’s needs.
Surveyors observed a medication cart on one nursing unit that was left unlocked and unattended in a hallway outside a room, with no staff present nearby. This situation was identified and reported to an LPN and later to the DON, demonstrating that medications were not consistently maintained in locked compartments as required.
A resident with a PRN order for Oxycodone 5 mg for left arm pain received multiple doses of this schedule II medication that were recorded on the controlled medication utilization record but not consistently documented on the MAR, and pain assessments were not completed or recorded for several administrations. The facility’s Medication Administration policy required staff to sign the MAR after giving medications and to sign the narcotic book for controlled substances, but the policy lacked implementation and revision dates, and the DON acknowledged that none of the facility’s policies had such dates. Review of the resident’s records showed a discrepancy between the 18 Oxycodone doses signed out on the controlled medication record and only 6 doses documented on the MAR, with several dates where Oxycodone was signed out but no corresponding MAR initials or pain assessments were recorded.
A resident did not receive an important piece of mail when staff failed to deliver an unopened letter from the local county DHS program that was later found in the facility activity area months after it was postmarked. During a complaint survey, the letter, still unopened and addressed to the discharged resident, was observed in the activity area, and the DON, when interviewed, was unable to explain why the resident had not received it.
Surveyors found that outdated food items, including mustard and bread, were not removed from storage as required, and a frozen meat item was left unlabeled and undated after being removed from its original packaging. Additionally, vegetables were rinsed in a non-designated sink, contrary to sanitary procedures. Dietary staff and the DoD confirmed these lapses in food storage, labeling, and preparation practices.
Surveyors found that two residents, both capable of making their own decisions, did not have documented evidence that advance directives were discussed or that information was provided. The Director of Social Services confirmed the absence of required documentation in both cases, despite facility procedures stating such discussions should occur on admission.
The facility did not promptly notify the physician or responsible party in two cases: one involving a resident who did not receive prescribed medication due to pharmacy unavailability, and another where a resident's ordered urine test was not completed and the lack of sample collection was not communicated. In both instances, documentation and staff interviews confirmed that required notifications were not made in a timely manner.
The facility did not ensure timely reporting of two separate abuse allegations. In one case, a resident's report of rough handling by a GNA was not communicated to the DON or reported to OHCQ within the required two-hour window. In another case, an incident involving a resident exposing themselves to another was reported to OHCQ more than two hours after the administrator was notified. The DON confirmed both incidents were not reported within the mandated timeframe.
Facility staff failed to accurately code the MDS assessment for a resident, marking antibiotic use for a UTI when there was no evidence in the medical or pharmacy records that antibiotics had been ordered or administered. The error was confirmed by the MDS coordinator and DON after review.
Facility staff did not complete required PASARR re-evaluations or Level II referrals for three residents whose initial screenings indicated the need for further assessment of mental disorder or intellectual disability. Medical record reviews and staff interviews confirmed that necessary follow-up screenings and documentation were not performed within the mandated timeframe.
Surveyors found that the facility did not develop or implement care plans for three residents: one with wounds, one receiving hospice care, and one taking antipsychotic and antidepressant medications. The absence of these care plans was confirmed by interviews with the DON and Unit Manager, and the residents' records lacked necessary interventions and approaches for their specific needs.
The facility did not conduct or document required interdisciplinary care plan meetings, failed to update care plans after changes in residents' cognitive status and therapy services, and continued to document therapy services after they were discontinued for two residents. Staff interviews confirmed lapses in documentation and communication regarding care plan updates and therapy discontinuation.
A resident who was fully dependent on staff for ADLs and had multiple co-morbidities did not receive scheduled showers as required, receiving only two bed baths without documentation of preference or refusal. This deficiency was identified after a complaint was made regarding the resident's hygiene upon transfer to a hospital, and the DON was unable to explain the lack of scheduled showers.
A resident receiving oxygen therapy did not have their oxygen tubing properly labeled with the date of change, was administered oxygen at a higher flow rate than ordered, and was given humidification without a physician's order. The LPN was unaware of the correct flow rate or last tubing change, and the care plan lacked specific goals and interventions for oxygen therapy. The DON confirmed these deficiencies.
Two residents receiving pain medications did not have documentation showing that nonpharmacological pain management interventions, as outlined in their care plans, were attempted prior to medication administration. The Treatment Administration Record lacked evidence that measures such as turning, music, or hot/cold applications were used before giving prescribed pain medications, and this was confirmed by the DON.
A resident with multiple cardiac conditions, including a left ventricular thrombus and low ejection fraction, did not receive timely follow-up with a cardiologist as recommended upon hospital discharge, and experienced an interruption in prescribed anticoagulation therapy. The attending physician was aware of these needs but did not ensure that a cardiology consult was ordered or documented, and responsibility for arranging the consult was deferred to facility staff.
The facility did not provide documentation that physicians reviewed or addressed irregularities identified by the pharmacist during monthly drug regimen reviews for two residents. Required reports were missing from the medical records, and the DON could not confirm whether the irregularities were communicated to or addressed by the physicians, as required by facility policy.
A resident with bipolar disorder was prescribed risperidone, and although psychiatric notes indicated stable mood and no behavioral concerns, required behavior monitoring associated with antipsychotic use was not documented in the Treatment Administration Record. The DON confirmed that the behavior monitoring tool, needed for psychiatric review and medication management, was not utilized.
A review of employee files revealed that an LPN was working with a non-renewed license, as confirmed through the Maryland Board of Nursing's verification system. The HR/Staff Scheduler tracked licenses using a spreadsheet and sent reminders, but this did not prevent the lapse. The DON and HR/Staff Scheduler were notified of the deficiency.
A resident admitted after a CVA due to a left ventricular thrombus was not provided with a timely cardiology consult as recommended upon hospital discharge. Despite documentation of the need for outpatient cardiology follow-up, no orders were placed and the consult was not arranged, with both the attending physician and DON acknowledging the lapse in coordination and follow-up.
A resident's hygiene care was not accurately documented, with inconsistencies between paper and electronic records regarding who performed and recorded bed baths. The staff member who provided care did not document in the EHR, and another staff member entered information without confirming the resident's preferences or refusals. The DON acknowledged discrepancies and could not verify if care was based on the resident's wishes.
A resident receiving hospice care did not have a hospice plan of care available in either paper or electronic records. Both the LTC Unit Manager and the DON confirmed the absence of this essential documentation, which is necessary to ensure the resident's needs are addressed and met during hospice services.
The facility did not provide evidence that its QAPI committee met at least quarterly as required, with missing documentation for certain periods and no paper records available. The DON reported that a computer system hack prevented access to electronic records.
A resident was transferred to the hospital following a fall, but the facility did not provide the required bed hold policy notification to the responsible representative. Staff interviews revealed confusion about the process, with some staff unaware of the policy and others unsure if it was sent to the responsible party. Only an admission acknowledgment was on file, and the DON was not aware of the mailing requirement.
Surveyors found that the facility did not display required daily nurse staffing information in a prominent and accessible location for residents and visitors. Both the DON and staffing coordinator were unaware of the posting requirement.
Failure to Honor MOLST DNR/DNI Orders and Misapplication of BP Parameters for Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s updated end-of-life wishes as documented on a revised Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form. One resident was initially admitted with a MOLST indicating full code status and all life-sustaining treatments. After a subsequent hospitalization and readmission, the attending physician documented an extensive discussion with the resident’s power of attorney and determined that the resident, who lacked capacity to make medical decisions and had multiple serious diagnoses including cerebrovascular accident with residual weakness, atrial fibrillation, diabetes, chronic anemia, gastrostomy tube, and metastatic prostate cancer to bone, was to be DNR/DNI with other measures permitted. A new MOLST form was completed indicating No CPR and Do Not Intubate, but the prior full-code MOLST was not voided by facility staff. When the resident later experienced a change in condition characterized by vomiting coffee-ground-like material, an LPN notified the on-call physician, obtained an order to transfer the resident to the hospital via 911, and prepared copies of the medical record, including medication orders and the MOLST form, for EMS. The LPN could not recall the specific contents of the MOLST form sent and only identified the resident as a hospital transfer. The attending physician stated they were unaware which MOLST form was sent with the resident. Review of the hospital record showed that the MOLST accompanying the resident was the earlier full-code form, labeled with the resident’s hospital information, and that the updated DNR/DNI MOLST had not been clearly communicated to EMS. As a result, the resident, who had documented DNR/DNI status on the newer MOLST, received CPR and intubation during EMS transport and was subsequently treated in the hospital ICU for 20 days. A second deficiency concerns the facility’s failure to follow specific physician-ordered blood pressure parameters for administering a cardiac medication to another resident. The physician ordered Lisinopril 10 mg by mouth once daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 100 mm Hg. Review of the medication administration records for two months showed that nursing staff withheld multiple doses of Lisinopril on days when the resident’s systolic blood pressure readings were between 106 and 109 mm Hg, all above the ordered hold parameter. In an interview, the LPN who withheld these doses confirmed they were responsible for the omissions and acknowledged that, upon re-reading the physician’s prescribed parameters, the doses should have been administered as ordered.
Failure to Notify Physician of Swallow Evaluation Results
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician of the results of a swallowing evaluation. A complaint was received by the Office of Health Care Quality alleging that staff did not notify the physician regarding the results of a swallowing test. Review of the closed clinical record for Resident #1 showed the resident was admitted with severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate, and had significant cognitive impairment with a BIMS score of 3/15. During admission, the facility SLP spoke with the resident’s responsible party, who reported that the resident had failed a swallowing test in the hospital but wanted another swallowing test to attempt a diet upgrade. The SLP obtained physician orders and scheduled a FEES exam to be completed at the facility. On the scheduled date, the FEES procedure was performed and the results were available to staff the same day. The FEES report recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids, along with compensatory strategies such as sitting upright, no straws, single sips, small bites, and a slow rate of intake, and suggested consideration of a PROVALE cup if single sips could not be completed independently. Despite the availability of these results and recommendations, there were no nursing progress notes in the resident’s chart indicating that the physician had been informed of the FEES results. In an interview, the DON confirmed that the record lacked documentation that the resident’s physician was made aware of the swallowing evaluation findings.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
Facility staff failed to immediately report an allegation of suspected resident abuse to local law enforcement after a resident was found to have a fractured left humerus. On 02/03/26, the Office of Health Care Quality (OHCQ) received a facility-reported incident concerning this resident’s injury, which was reported by the facility as an injury of unknown source. A subsequent 5-day follow-up investigation by the facility, reviewed on 03/03/26, documented that an x-ray confirmed the left humerus fracture, that there were no witnesses to the incident, and that the resident was unable to tell staff how the injury occurred. The facility’s investigation concluded that the cause of the injury was inconclusive and that abuse had been ruled out. During the investigation, the facility measured the resident’s Brief Interview for Mental Status (BIMS) and recorded a score of 13/15, while noting that the resident’s BIMS score fluctuates. A review of the facility’s abuse policy on 03/05/26 showed that the facility designates an Abuse Prevention Coordinator responsible for reporting allegations or suspected abuse, neglect, or exploitation to the State Survey Agency and other officials in accordance with State law. Despite this policy and the requirement that allegations of abuse be reported to both OHCQ and local police in a timely manner, the 5-day follow-up investigation indicated that the allegation was not reported to law enforcement. In an interview on 03/11/26 during the exit conference, the administrator and DON confirmed that law enforcement had not been notified of the allegation related to the resident’s fractured humerus.
Failure to Revise Nutritional Care Plan After Swallowing Assessment
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect updated swallowing assessment results and related nursing interventions. A resident was admitted with diagnoses including severe calorie malnutrition, pharyngeal dysphagia, dementia, and malignant neoplasm of the prostate, and had a BIMS score of 3/15, indicating severe cognitive impairment. The dietician developed a nutritional risk care plan dated 12/29/25, with goals for the resident to tolerate a modified diet texture/consistency and maintain adequate nutritional status, and interventions such as administering medications as ordered, monitoring and reporting signs and symptoms of dysphagia, providing 1:1 assistance with meals as needed, providing supplements, serving the ordered diet and monitoring intake, and having the dietician evaluate and recommend diet changes as needed. During the admission process, the facility SLP evaluated the resident on 12/30/25 and, after discussion with the responsible party, obtained physician orders and scheduled a FEES exam, which was completed on 01/09/26. The FEES results recommended a soft and bite-sized/mechanical soft chopped diet with thin liquids and compensatory strategies including sitting upright, no straws, single sips, small bites, and a slow rate of intake, with consideration of a Provale cup if single sips were not completed independently. These FEES results were available to staff the same day. However, interview with an RN on 03/05/26 confirmed that the resident’s Nutritional Risk care plan was not updated with any new nursing interventions following the 01/09/26 FEES procedure, leading to the determination that the facility failed to revise the care plan to meet the resident’s needs.
Unlocked and Unattended Medication Cart in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were kept in locked compartments as required. During observation of one of four nursing units (the 100 hall), a surveyor observed a medication cart unlocked and unattended in the hallway outside a resident room. At the time of this observation, no staff members were present around the medication cart. The unlocked and unattended cart was identified by the surveyor and then brought to the attention of a licensed practical nurse, and the observation was later reported to the director of nurses. No additional information about specific residents, their medical histories, or conditions at the time of the deficiency is provided in the report.
Incomplete Documentation of Controlled Pain Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records, specifically related to medication administration documentation for one resident. The facility’s Medication Administration policy instructs nursing staff to sign the Medication Administration Record (MAR) after administering medications and to sign the narcotic book for controlled substances; however, the policy itself lacked implementation and revision dates and did not identify who reviewed or revised it. During an interview, the DON stated that none of the facility’s policies and procedures had dates indicating when they were implemented. A physician’s order dated 02/04/26 directed staff to administer Oxycodone 5 mg orally every 6 hours as needed for left arm pain greater than 5/10 for 30 days. Review of the resident’s controlled medication utilization record showed that nursing staff administered 18 doses of Oxycodone 5 mg between 02/05/26 and 03/09/26, while the February and March MARs reflected documentation of only 6 administered doses during that same period. For three of the documented doses, the MAR entries recorded pain scores of 3/10 and 0/10 at the time of administration. Further review revealed that on multiple specific dates and times, staff signed out Oxycodone on the controlled medication utilization record but failed to perform and document pain assessments and failed to initial the MAR to show administration of the 5 mg Oxycodone doses. This discrepancy between the controlled substance record and the MAR, along with missing pain assessments, demonstrated that the facility did not have an effective system to ensure complete and accurate clinical documentation for this resident’s medication administration.
Failure to Deliver Resident Mail from County DHS Program
Penalty
Summary
Facility staff failed to ensure a resident received mail, resulting in an unopened letter addressed to Resident #5 being found in the facility activity area. During an observation of the first-floor activity area at 2:00 p.m. on 03/04/26, surveyors observed an unopened letter addressed to Resident #5 from the local county DHS program, postmarked 10/24/25. A review of Resident #5’s closed record showed that the resident had been admitted and later discharged home, though the specific dates were not detailed in the report. When the DON was interviewed at 3:32 p.m. the same day and handed the letter, the DON stated that Resident #5 had recently been discharged and could not provide any explanation for why the resident had not received the letter when it arrived in October 2025. This deficiency was identified for 1 of 8 residents reviewed during a complaint survey and demonstrates that the facility did not ensure reasonable access to and privacy in the use of communication methods, specifically mail delivery, for Resident #5.
Deficiencies in Food Storage, Labeling, and Sanitary Practices
Penalty
Summary
Surveyors identified several deficiencies related to food storage, preparation, and labeling during a kitchen tour. Outdated nourishment, specifically a quarter jar of yellow mustard with an open date several months prior, was found in the refrigerator and had not been removed as required. Additionally, two and a half loaves of sliced bread with an expiration date that had already passed were also found in the refrigerator. An unlabeled and undated frozen meat item was discovered in the freezer, and staff confirmed that it should have been labeled and dated immediately after being removed from its original packaging. Further observations revealed that a tray containing celery, onions, and green peppers was placed in the manual rinse compartment of the three-compartment dishwasher sink, rather than the designated food preparation sink. Staff admitted to sometimes rinsing vegetables in the incorrect area, acknowledging that this was not in accordance with proper sanitary procedures. These findings were confirmed through interviews with dietary staff and the Director of Dietary, who acknowledged that the observed practices did not meet required standards.
Failure to Document Advance Directive Discussions and Provision of Information
Penalty
Summary
The facility failed to ensure that advance directives were discussed with, and information regarding advance directives was provided to, residents and/or their responsible representatives. For one resident who had the capacity to make their own decisions, there was no documented evidence that the facility provided education about or obtained an advance directive. The Director of Social Services confirmed that no advance directive documentation was found for this resident, despite the facility's stated process of evaluating residents on admission and offering the opportunity to formulate advance directives if none were present. For another resident, the medical record included a Maryland Order for Life Sustaining Treatment (MOLST) and a certificate of capacity indicating the resident was cognitively intact and capable of making decisions. However, there was no advance directive document found in either the paper chart or electronic medical record, and no documentation that a discussion about advance directives had occurred with the resident or their responsible party. The Director of Social Services confirmed that the admission assessment and social services progress notes did not document any discussion or provision of information regarding advance directives for this resident.
Failure to Timely Notify Physician and Responsible Party of Medication and Diagnostic Test Issues
Penalty
Summary
The facility failed to notify the physician, Medical Director, or responsible party in a timely manner regarding two separate incidents involving two residents. In the first case, a resident was prescribed Benadryl anti-itch cream, but the medication was not available from the pharmacy for three days. Documentation showed that staff were aware of the unavailability and that the medication was not administered as ordered, but there was no timely notification to the physician or a change in medication until three days after the initial order. The resident's family only became aware of the issue through the resident, not from facility staff. In the second case, a resident experienced a change in condition, prompting new orders for diagnostic urine testing via in-and-out catheterization every shift for two days. The health record did not show that attempts were made to obtain the urine sample on one of the days, nor was there documentation that the physician or responsible party was notified of the missed collection and incomplete test. The lack of notification persisted until the resident was transferred to the hospital, at which point the physician and family were informed. The DON confirmed that both the physician and responsible party should have been notified of the inability to obtain the urine specimen.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations for two residents. In the first instance, a resident reported to a unit manager that a Geriatric Nursing Assistant was rough during care, describing the staff as a white woman with yellow hair who did not allow enough time for the resident to turn and handled the resident roughly. Despite this report, there was no evidence that the incident was communicated to the Director of Nursing (DON), the Administrator, or the Office of Healthcare Quality (OHCQ) within the required timeframe. The DON confirmed she had not been informed of the incident, and no documentation was provided to show that the allegation was reported to OHCQ within two hours as required. In the second instance, an ancillary staff member observed a resident exposing their private area to another resident. The facility administrator was notified of this allegation, but the report to OHCQ was made more than two hours after the administrator was informed. The DON acknowledged the late reporting after reviewing the documentation and confirmed that the report was not made within the mandated timeframe. These failures demonstrate that the facility did not adhere to timely reporting requirements for abuse allegations.
Inaccurate MDS Coding for Antibiotic Use
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident reviewed for antibiotic use. During an interview, the resident denied having a urinary tract infection (UTI) and was unsure about taking antibiotics. However, the facility's 30-day admissions matrix indicated that the resident was taking antibiotics for a UTI. Upon further review of the resident's medical records, including pharmacy orders and medication administration records, there was no evidence that antibiotics had been ordered or administered to the resident. The MDS assessment for the resident, dated March 23, 2025, was coded to indicate antibiotic use in Section N0415. The MDS coordinator confirmed that there were no antibiotics found in the resident's current or discontinued medication records. The coordinator explained that the assessment was completed by a weekend MDS coordinator and acknowledged that the coding for antibiotic use was incorrect. The Director of Nursing also agreed that the MDS assessment was inaccurately coded.
Failure to Complete Required PASARR Re-Evaluations and Referrals
Penalty
Summary
Facility staff failed to ensure that required PASARR (Preadmission Screening and Resident Review) screenings were re-evaluated and completed as mandated for residents with indications of mental disorder or intellectual disability. For three residents reviewed, the initial Level I PASARR screens indicated the need for further evaluation (Level II PASARR) or re-screening if the stay extended beyond 30 days. However, there was no evidence in the clinical records that these follow-up screenings or referrals to the appropriate agencies were completed within the required 40-day timeframe. The deficiency was identified through medical record reviews and staff interviews, which confirmed the absence of updated PASARR documentation and necessary Level II evaluations. Specifically, one resident had a Level I PASARR screen indicating the need for a Level II evaluation, but no such evaluation was found in the records. Another resident's PASARR form also indicated the need for re-evaluation and referral, but again, no evidence of a Level II screen was present. For a third resident, the PASARR Level I form responses required a Level II evaluation, but staff acknowledged that this was not completed. These findings were corroborated by interviews with the Director of Social Services and the DON, who confirmed the lack of required follow-up PASARR documentation and evaluations.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement complete care plans for three residents, as identified during a Medicare/Medicaid recertification and complaint survey. One resident was admitted with a history of epilepsy, hemiplegia, and hemiparesis, and had both a stage 2 pressure wound and a venous wound documented by the wound team. Despite these findings, there was no care plan in place addressing the management of the resident's wounds. Interviews with the Unit Manager and DON confirmed that a wound care plan should have been created but was not present in the resident's record. Another resident with a terminal prognosis was admitted to hospice care, but the facility did not initiate a hospice care plan. The Unit Manager and DON both acknowledged the absence of a hospice care plan for this resident. Additionally, a third resident was receiving antipsychotic and antidepressant medications for depression and bipolar disorder, but the care plan did not include any focus, goals, or interventions related to these medications. The DON confirmed that a comprehensive care plan addressing the use of these medications was not developed or implemented.
Failure to Conduct and Update Interdisciplinary Care Plans and Therapy Documentation
Penalty
Summary
The facility failed to conduct required interdisciplinary care plan meetings, update care plans to reflect residents' current needs, and revise care plans following changes in therapy services. For one resident, there was no documentation that care plan meetings were held after each Minimum Data Set (MDS) assessment, nor evidence that the resident or their family representative was included or notified of these meetings. Staff interviews confirmed that attempts to contact family representatives were not documented, and there was a lack of evidence supporting that care plan meetings occurred as required. Additionally, the care plan for this resident was not updated to reflect changes in cognitive status or interventions following an incident involving wandering and inappropriate behavior. Although interventions for elopement and impaired safety awareness were in place, there was no recent review or revision of these interventions, and the last elopement assessment was outdated. The Director of Nursing acknowledged that the care plan interventions were not current and that the resident was no longer at risk for elopement. For another resident, the care plan was not updated after the discontinuation of Physical Therapy (PT) and Occupational Therapy (OT). Despite therapy services being discontinued, nursing staff continued to document that the resident was receiving PT and OT, and the care plan still reflected ongoing therapy. The Director of Nursing confirmed that care plans should have been updated to reflect the discontinuation of services and that staff should not have documented services that were not provided.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident with multiple co-morbidities who was dependent on staff for all activities of daily living (ADL) was admitted to the facility and was scheduled to receive showers twice per week on Mondays and Thursdays during the 3 pm to 11 pm shift. During a complaint investigation, it was found that the resident did not receive any showers during their stay at the facility, as documented in the shower log. Instead, the resident received only two bed baths, with no documentation indicating that this was based on the resident's preference or that showers were offered and refused. The deficiency was identified after a complaint was made regarding the resident's hygiene when transferred to a hospital, where a hospital nurse observed the resident to be dirty. The Director of Nursing (DON) confirmed that the resident was supposed to receive scheduled showers and was unaware of why this did not occur. The lack of proper documentation and failure to provide the scheduled showers led to the deficiency cited during the Medicare/Medicaid recertification and complaint survey.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not properly labeling oxygen tubing with the date it was changed, not following the physician's order for the prescribed oxygen flow rate, and not developing or implementing a comprehensive, person-centered care plan for oxygen therapy. During observation, a resident was found using a nasal cannula connected to a humidifier bottle and oxygen concentrator set at 4 liters per minute (LPM), while the physician's order specified 2 LPM via nasal cannula. The oxygen tubing was not labeled with the date or time of the last change, and the nurse on duty was unable to confirm when the tubing was last changed or the correct flow rate for the resident's oxygen therapy. Review of the resident's medical record revealed orders for weekly oxygen tubing changes and continuous oxygen at 2 LPM, but there was no order for the use of a humidifier bottle. Documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not indicate the use of humidification, and the care plan lacked a focus on oxygen therapy with specific goals and interventions. The Director of Nursing confirmed these deficiencies, noting that the oxygen tubing should be labeled and that oxygen therapy should be addressed in the care plan.
Failure to Document Nonpharmacological Pain Management Interventions
Penalty
Summary
The facility failed to document the use of nonpharmacological interventions for pain management for two residents who were prescribed pain medications. For one resident, a physician order was in place for Roxicodone to be administered as needed for pain or prior to physical therapy. The resident's care plan specified that nonpharmacological interventions such as turning and repositioning, music, television, low light, hot or cold applications, and noise reduction should be used for pain management. However, a review of the Treatment Administration Record (TAR) revealed no documentation that these interventions were attempted or implemented prior to administering pain medication. Similarly, another resident had a physician order for tramadol for pain, and their care plan also directed nursing staff to use nonpharmacological pain management strategies. Upon review, there was no evidence in the TAR that these interventions were documented as being used before administering the medication. An interview with the Director of Nursing confirmed that the care plan interventions should have been added to the TAR and acknowledged the lack of documentation to validate the use of nonpharmacological measures.
Failure to Ensure Timely Cardiology Consult and Continuity of Anticoagulation Therapy
Penalty
Summary
A deficiency occurred when the attending physician failed to follow up on hospital discharge recommendations and her own notes regarding a necessary cardiology consult for a resident with significant cardiac conditions, including a left ventricular thrombus, low ejection fraction, prior stroke, ischemic cardiomyopathy, and coronary artery disease. The resident was discharged from the hospital with instructions to follow up with a cardiologist within three months and to continue anticoagulation therapy for at least three months. However, the medical record review revealed that the resident's anticoagulant was discontinued for approximately one month within two months of admission, and there was no documented evidence of a cardiology consult being ordered or completed during this period. During interviews, the attending physician acknowledged awareness of the need for a cardiology consult and the importance of continued anticoagulation but deferred responsibility to the facility for arranging the consult. She also could not confirm whether the resident had seen a cardiologist and admitted that any order for a consult may have been given verbally, with no documentation found in the chart. The Director of Nursing was also made aware of the attending physician's lack of follow-through on the resident's care plan, specifically regarding the cardiology consult and monitoring of the resident's cardiac condition.
Failure to Document Physician Review of Pharmacy-Identified Drug Regimen Irregularities
Penalty
Summary
The facility failed to provide documentation that the attending physician reviewed irregularities identified by the pharmacist during monthly drug regimen reviews for two residents. For one resident, there were four dates on which the pharmacist identified irregularities, but the facility was only able to locate documentation for one of those dates. The remaining records could not be found, and there was no proof that the reviews were completed or seen by the appropriate discipline. The facility's own policy requires that the pharmacist communicate irregularities in writing to the attending physician, medical director, and DON, and that these communications become a permanent part of the resident's medical record. For another resident, two dates were identified where the pharmacist noted irregularities and made recommendations, but the facility could not provide the corresponding reports in the resident's chart. The DON stated that the pharmacist sends consultation reports via email, which are then printed and given to unit managers to follow up with physicians. However, the DON was unable to find the reports or confirm whether the physician had reviewed or addressed the irregularities. No additional documentation was provided to show that the irregularities were addressed by the physician.
Failure to Implement Behavior Monitoring for Antipsychotic Use
Penalty
Summary
The facility failed to implement behavior monitoring for a resident who was prescribed antipsychotic medication. Medical record review showed that the resident was admitted with a diagnosis of bipolar disorder and had a physician's order for risperidone. Psychiatry consult notes indicated the resident was stable, with no reports of sleep disturbances, appetite changes, suicidal or homicidal ideation, hallucinations, or delusions, and no observed agitation or aggression. The psychiatrist's plan included considering a gradual dose reduction or discontinuation of risperidone if stability continued. However, review of the Treatment Administration Record revealed that behavior monitoring, which is required for residents receiving antipsychotic medications, was not documented. The Director of Nursing confirmed that the behavior monitoring tool was not used, which was necessary for the psychiatrist to make informed decisions regarding medication management.
LPN Worked Without Active License
Penalty
Summary
The facility failed to ensure that all nursing staff maintained an active license as required by state law. During a review of five employee files, it was discovered that one LPN was working with a license status of NON-RENEWED, with the expiration date having already passed. The Maryland Board of Nursing's online verification system was used to confirm the license status. The Human Resource/Staff Scheduler reported using a spreadsheet to track license expirations and sending reminders to employees, but this process did not prevent the lapse in licensure for the LPN. Both the Human Resource/Staff Scheduler and the Director of Nursing were made aware of the issue during the survey.
Failure to Arrange Timely Cardiology Consult for Resident with LV Thrombus
Penalty
Summary
A deficiency was identified when the facility failed to provide timely access to outside professional services for a resident who required specialized care. The resident was admitted following a cerebral vascular accident (CVA) caused by a left ventricular (LV) thrombus and was discharged from the hospital with instructions to continue anticoagulation therapy for at least three months, with a follow-up cardiology assessment and repeat imaging recommended. Review of the resident's medical records showed that, over the course of a year, there was only one physician note referencing the need for an outpatient cardiology consult, and no orders were placed to arrange this consult. Interviews with the attending physician and the Director of Nursing (DON) revealed a lack of follow-through on the recommendation for a cardiology appointment. The attending physician stated that while recommendations could be made verbally or in writing, it was the facility's responsibility to ensure the appointment was scheduled. The DON was made aware of the concern regarding the absence of a cardiology consult for the resident, highlighting a breakdown in coordination and follow-up for required outside professional services.
Failure to Accurately Document Resident Hygiene Preferences and ADL Care
Penalty
Summary
The facility failed to ensure accurate and consistent documentation of a resident's personal hygiene preferences and the completion of activities of daily living (ADL) care. Specifically, for one resident, there were discrepancies between the paper shower log and the electronic health record (EHR) regarding who performed and documented bed baths on two separate dates. The paper shower log indicated that a Geriatric Nursing Assistant (GNA) provided the care, while the EHR showed that an LPN and a different GNA documented the same tasks. The staff member who performed the care did not document in the EHR, and another staff member documented on their behalf without confirming the resident's preferences or whether a shower was offered and refused. Interviews with staff revealed that the GNA responsible for providing the bed baths only documented in the paper shower log and did not use the EHR for any residents. The LPN confirmed that she documented in the EHR when the person who completed the task had not done so, rather than ensuring the actual caregiver completed the documentation. The Director of Nursing acknowledged the mismatch in documentation and was unable to confirm if the resident's hygiene care was based on their preferences or if refusals were properly recorded.
Failure to Maintain Hospice Plan of Care Documentation
Penalty
Summary
A deficiency was identified when a resident with a terminal prognosis, who was receiving hospice services, did not have a hospice plan of care available in either the paper or electronic medical records. During a review of the resident's records, surveyors were unable to locate the required hospice plan of care or documentation of the communication process related to hospice services. The absence of this documentation was confirmed by the Long-Term Care Unit Manager, who acknowledged that the plan of care should have been present in the resident's health records. Further inquiry revealed that the Director of Nursing was also unable to provide the hospice plan of care at the time of the initial request and was waiting for the necessary documents to be sent from the hospice provider. The lack of a hospice plan of care meant that there was no documented guidance to ensure the resident's needs were being addressed and met as part of their hospice care.
Failure to Hold and Document Required QAPI Committee Meetings
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly as required. Review of the Quality Assurance Committee sign-in sheets for the period from January 2024 to March 2025 showed that meetings were held on several dates, but there was no documented evidence of a meeting in June 2024 or for certain other periods. During an interview, the DON stated that the facility's computer system had been hacked and that no paper documentation was available to verify the missing meetings. This lack of documentation and failure to meet the required frequency of QAPI meetings was identified during the recertification/complaint survey.
Failure to Provide Bed Hold Policy Notification on Resident Transfer
Penalty
Summary
The facility failed to provide the required bed hold policy notification to the responsible representative when a resident was transferred out to the hospital. Medical record review showed that the resident had multiple hospital transfers, with the most recent involving a fall and subsequent transfer via 911. While the resident had acknowledged receipt of the bed hold policy upon admission, there was no evidence that a copy was provided or mailed to the responsible representative at the time of the most recent transfer. Staff interviews revealed inconsistencies and lack of awareness regarding the process for distributing the bed hold policy during transfers. One nurse was unfamiliar with the bed hold policy, while another stated the policy was given to the resident but was unsure if it was sent to the responsible representative. The Admissions Director indicated that nursing was responsible for this task, but also confirmed that only the admission acknowledgment was on file. The DON was not aware of the requirement to mail the policy to the responsible representative upon transfer.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent and accessible location for residents and visitors. During the recertification and complaint survey, surveyors observed that no nurse staffing information was displayed at the main entrance or in common areas from 4/9/25 through 4/17/25. Interviews with the DON and the staffing coordinator revealed that both were unaware of the requirement to post this information in a location easily accessible to visitors and staff. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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