South River Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Edgewater, Maryland.
- Location
- 144 Washington Road, Edgewater, Maryland 21037
- CMS Provider Number
- 215297
- Inspections on file
- 22
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at South River Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete accurate MDS assessments for three residents. One resident admitted with a shoulder fracture from a fall at home was incorrectly coded on the 5-day MDS as having two in-facility falls, including one with major injury, even though the DON confirmed no falls occurred after admission. Another resident who had two documented falls in the facility had those events correctly coded on an End of PPS Part A Stay MDS, but the same two falls were inappropriately re-coded as new events on a later discharge MDS despite no additional falls. A third resident’s Quarterly MDS was coded to show seven days of insulin injections in Section N0350, although the EMR contained no insulin orders; the MDS Coordinator stated Ozempic had been mistakenly coded as insulin.
Physical Environment Not Maintained on Station 2: Several resident rooms on station 2 had marred doors, doorframes, and walls, along with loose or missing tile around sinks, a warped sink counter, a drawer out of alignment, and a bathroom door with holes and peeling paint. The Maintenance Director acknowledged the disrepair and said repairs depended on budget, and the LNHA was later notified of the concerns.
Improper food storage and labeling were observed in the kitchen, service area, and a unit nourishment refrigerator/freezer. The FSD and District Manager found shoes, disposable gloves, and a personal lunch bag stored in kitchen areas, along with carts and boxes of chemicals on the floor in the service hall. The DON also confirmed that resident food in the nourishment refrigerator/freezer should be labeled with resident name and date, yet multiple items were found not dated or not labeled, including a pizza box, fruit container, food bag, vegetables, and frozen drink cups.
Inconsistent Hand Hygiene During Medication Administration: An LPN was observed administering medications to multiple resident rooms without performing hand hygiene between resident interactions, and another LPN was observed with the same issue. Hand hygiene was only noted after leaving rooms during medication passes, and the IP President acknowledged the concern.
A resident was transferred from one room and nursing station to another, but there was no documentation in the medical record that the resident or responsible party was notified of the room change. During interviews, the DON acknowledged that facility expectations require notification and documentation of room changes, yet no record of such notification could be found or produced to surveyors.
Failure to Notify Provider and RP of Significant Weight Loss: A resident with impaired decision-making capacity lost 18 lbs in less than 3 months, with survey observations showing poor meal intake and only drinks or juices consumed at meals. Although the dietitian documented the weight loss and increased nutritional supplements and monitoring, the record did not show that the provider or RP were notified of the significant change in condition.
Failure to provide hearing services for a resident with documented hearing loss. The resident used a journal to communicate, staff reportedly spoke loudly to the resident, and the resident said the facility had assessed hearing but had not followed up. Records showed moderate difficulty hearing, a care plan for poor hearing, and an audiology eval finding moderately severe to profound sensorineural hearing loss in both ears with a recommendation for hearing aids and medical clearance.
Failure to clarify and document left hand splint care for a resident with a contracted hand. The resident was observed with the hand contracted and no splint visible, while the chart contained two splint orders with different directions. The TAR did not include either order, and there was no documentation showing the splint was applied or removed as ordered; the UM gave conflicting statements about whether the splint care was documented and which order should be followed.
Failure to order recommended lab monitoring for a resident with a recent hospital discharge and transplant history. The provider acknowledged the resident’s transplant and medications, but did not include the ordered BMP and hematocrit monitoring in the new patient note. The DON confirmed that only one lab order had been written, even though weekly labs were recommended while the resident was in rehab.
Incorrect Diazepam Dosage and Pharmacy Delivery Failure: A resident’s active Diazepam order did not match the pharmacy script, and staff reported splitting whole 2 mg tablets to give 1.5 tablets as ordered. The pharmacy technician confirmed the active script had been received but said the correct partial-tablet supply had not yet been delivered, while the facility’s med admin policy prohibited splitting tablets and required contacting the pharmacy for the correct dose. The resident’s bubble pack and control sheets for the prior supply were still present during med pass.
Controlled Medication Labeled and Stored Improperly: A resident's Diazepam bubble packet did not match the active MAR order, as the packet reflected a discontinued dose while the current order was for 1.5 tabs with hold-for-sedation instructions. An LPN administered the dose, returned half a tab to the previously punctured bubble, and later reported that the half tab was wasted; the Unit Manager acknowledged the concern.
A resident needed dental extractions and was initially told the safest course was oral surgery under GA in a hospital setting, but the referral was not acted on for months. In-house dental notes later continued to recommend FMX, extractions of retained roots, and dentures, yet x-rays were not completed and extraction attempts were unsuccessful; the DON acknowledged the hospital oral surgery process was not started until much later.
A resident with a documented dairy allergy/intolerance continued to receive milk on meal trays. The FSD stated the resident’s preference to avoid dairy was noted on tray tickets, but the surveyor observed whole milk on the breakfast tray and the tray ticket also listed milk, which the FSD later said was incorrect.
Open Dumpster Door Observed Outside Facility: Surveyors observed one of the outside trash dumpsters with its lid/door left open during multiple observations. The FSD stated the lid should be closed, and later the Mnt Dir noted staff had recently taken trash out and did not close the dumpster door.
Inaccessible Bathroom Call Lights: Surveyors observed that two residents had bathroom call light issues on a station 2 unit, including one shared bathroom with a pull cord that was too short and another with no pull cord attached to the call light panel. The MDS stated resident bathrooms should have accessible call lights, and the residents were later observed with accessible pull cords.
The facility failed to maintain a safe and homelike environment, with issues such as damaged baseboards, stained ceiling tiles, and exposed pipes. Additionally, a resident's personal property was not adequately protected from wandering residents, leading to broken and missing items. The resident, who was alert and oriented, expressed ongoing concerns about safety and security.
The facility failed to protect residents from abuse in two incidents. In one case, a resident was found undressing and inappropriately touching another resident, leading to police involvement and arrest. In another incident, two residents were found intertwined, resulting in one being pushed and falling. Both cases highlight the facility's inability to maintain a safe environment.
The facility failed to provide necessary personal hygiene care for two residents dependent on staff for assistance with ADLs. One resident with an ileostomy did not receive documented ostomy care until weeks after admission, and another resident had unkempt toenails that were only addressed after a complaint. Both residents were documented as needing significant assistance with personal hygiene, highlighting a deficiency in care.
A resident fell off the bed while a GNA was providing incontinent care, despite the care plan requiring two people for repositioning. The resident, who was dependent and required assistance for toileting hygiene, was evaluated at a hospital with no injuries found. The DON confirmed only one GNA was present during the incident.
A resident with a history of traumatic brain injury and severe spasticity experienced inadequate pain management due to the facility's failure to monitor and assess an intrathecal baclofen pump. The nursing staff lacked training on the pump's care, leading to insufficient documentation and oversight of the pump's function and effectiveness.
A facility failed to ensure accurate documentation and review of a resident's care plan after a visit. The resident, who had a PEG tube, had medication orders that were not updated to reflect the change from oral to PEG tube administration. Both the NP and Physician documented incorrect medication routes, and the DON could not confirm the correct administration route. The MD acknowledged an oversight in the medication administration route.
Surveyors found that the facility failed to maintain an effective pest control program, as evidenced by the presence of gnats in various areas, including resident care areas and the kitchen. Despite reports of gnats from 2017 to 2022, there was no documentation of resolutions. The Maintenance Director confirmed the issue but could not provide documentation of treatment or prevention efforts.
A facility failed to maintain a dignified environment for a resident by continuing to use a plastic bag to line the commode after the resident was cleared from a stomach infection. Staff interviews revealed uncertainty and continuation of the practice without necessity.
A facility failed to ensure a resident's call bell was within reach, as observed during a survey. On multiple occasions, the call bell was found on the floor, out of reach. A GNA and an LPN confirmed the issue and placed the call bell back within reach. The RN Unit Manager and DON acknowledged the facility's policy that call bells should always be accessible.
The facility failed to document whether a resident had an advance directive upon admission and did not ensure the accuracy of another resident's MOLST form. One resident's medical record lacked documentation of an advance directive, and the DON confirmed the absence due to the resident's inability to make decisions. Another resident's MOLST form had a blank decision-making section, despite an advance directive on file, which was acknowledged as an omission by the DON and Administrator.
The facility failed to notify two residents and/or their representatives of the bed hold policy upon hospital transfer. In one case, a bed hold was initiated without documented communication, and in another, the representative was not informed for a subsequent transfer. The Admissions Director acknowledged the oversight and has since been notifying all parties for hospital transfers.
The facility failed to accurately document MDS assessments for two residents, leading to deficiencies in their medical records. One resident with a colostomy was incorrectly coded as having no appliances, while another resident on hospice was inaccurately documented as not receiving hospice services. The MDS Director acknowledged these errors during interviews with surveyors.
A facility failed to conduct a new PASARR Level I screening after a resident was diagnosed with bipolar disorder during their stay. Initially, the resident was admitted with a PASARR Level I screening that did not indicate the need for a Level II evaluation. The deficiency was identified during a recertification survey, and the facility's staff acknowledged the oversight.
A facility failed to include dietary and nutritional needs in the baseline care plan for a resident with a complex medical history, including congestive heart failure and dementia. The omission was identified during a review of the resident's records, which showed that while other care plans were initiated, the dietary plan was not included within the required 48-hour timeframe.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a urinary device lacked a corresponding care plan, another resident had a missing lens in their glasses with no action taken, and a third resident with a colostomy did not have a care plan for colostomy care. Interviews with staff confirmed these oversights.
A facility failed to update a resident's care plan after readmission, omitting necessary revisions for anticoagulant and antianxiety medications. The resident, initially admitted and later readmitted, had physician orders for Apixaban and Clonazepam, but the new care plan did not reflect these medications. The DON confirmed the oversight during a surveyor's record review.
The facility failed to administer and document care as ordered for two residents. A resident with constipation did not receive prescribed as-needed medications despite not having bowel movements for several days, and another resident with a urinary catheter had no documentation of urinary output as required. The DON confirmed these deficiencies.
A resident in the facility had been missing a lens from their glasses for months and had not seen an ophthalmologist since admission, despite informing staff and having a consult ordered. The Director of Nursing confirmed the lack of follow-up on the resident's vision needs.
A facility failed to provide adequate colostomy care for a resident, as there was no physician order for the care of the colostomy. The resident was observed with a colostomy bag, but a review of medical records confirmed the absence of a physician order. The RN Unit Manager and the DON acknowledged the oversight, which was only addressed after surveyor intervention.
A facility failed to maintain 'oxygen in use - no smoking' signage for a resident requiring continuous oxygen therapy. Despite a physician's order and documented use of oxygen every shift, the necessary safety signage was not observed on multiple occasions. The RN Unit Manager acknowledged the requirement for signage and suggested it may have fallen off, indicating a lapse in maintaining safety protocols.
The facility failed to ensure residents' medication regimens were free from unnecessary drugs. One resident received duplicate sodium chloride doses due to overlapping orders, while another was given levofloxacin despite hospital instructions to stop the medication. These issues highlight a lack of proper medication management and order updates.
A facility failed to coordinate routine dental services for a resident, whose teeth were observed to be black by their representative. A dental consult was ordered, and the resident was last seen by the Dental Group, which recommended biannual cleanings. However, the DON stated that specialty care groups are responsible for scheduling, leading to a lack of coordination in ensuring timely dental care.
A facility failed to maintain accurate records for a resident transferred to the hospital. The transfer form lacked the name of the notified representative, although the date and time were recorded. An LPN confirmed notifying the representative but did not lock the note until later, resulting in incomplete records. The DON acknowledged the issue of missing information due to unlocked notes.
A facility failed to follow proper infection control practices by using a plastic bag to line a commode for a resident, even after the resident's stomach infection was cleared. Staff were unsure of the correct disposal method, and the DON clarified that waste should be disposed of in biohazard bags.
A facility failed to notify and obtain consent from a resident's representative for immunizations. The resident, with a BIMS score indicating severe cognitive impairment, had verbal declinations for vaccinations signed by the Infection Preventionist without consulting the representative. The oversight was acknowledged by the facility's staff, highlighting a lapse in following proper procedures for residents unable to make their own medical decisions.
Inaccurate MDS Coding for Falls and Insulin Use
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents. For one resident admitted from the hospital with a closed left scapular fracture after a fall at home, the Admission/Medicare 5-Day MDS dated 2/13/2026 was coded in Section J1800/1900 to show two falls since admission to the facility, one with no injury and one with a major injury. Record review showed the resident had not experienced any falls in the facility since admission on 2/9/2026, and the DON confirmed there were no in-facility falls for this resident. The inaccurate coding therefore reflected falls that did not occur during the resident’s stay. Another resident’s record showed two documented in-facility falls, one on 2/11/2026 with no injury and one on 2/16/2026 with injury (except major). These two falls were correctly captured on the 2/20/2026 End of PPS Part A Stay MDS in Section J1800/1900 as one fall with no injury and one fall with injury (except major). However, the subsequent Discharge Return Anticipated MDS dated 2/28/2026 was also coded to show one fall with no injury and one fall with injury (except major), despite there being no documentation of any additional falls after those already recorded on the 2/20/2026 assessment. The DON confirmed that the resident had only the two documented falls and no further incidents. For a third resident, the Quarterly MDS assessment dated 2/26/2026 contained inaccurate medication coding. In Section N0350 (Insulin), the assessment indicated that insulin injections were received on seven days during the look-back period. Review of the electronic medical record revealed there were no orders for insulin for this resident. During interview, the MDS Coordinator explained that Ozempic had been coded as an insulin, and acknowledged this as an error. These findings demonstrate that the facility did not consistently perform accurate MDS assessments for falls and insulin use as required by the assessment tool.
Physical Environment Not Maintained on Station 2
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents on station 2 nursing unit. During the initial tour, several resident rooms were observed with walls, doors, door frames, and sink counters in disrepair and in need of maintenance and repair. Specific observations included marred doors and doorframes in rooms 211, 212, 214, 216, 217, 220, 221, 222, 225, 226, 227, and 228; marred walls in rooms 213, 221, 227, and 228; loose tile around the sink in room 215; a warped sink counter in room 216; missing tile around the sink in room 218; a bedside dresser drawer not aligned on its track in room 227; and a bathroom door with two holes in the wood and peeling paint on the bathroom wall adjacent to the sink in room 230. Room 218 also had no remote for the television. The Maintenance Director was interviewed and stated that he had a plan to repair the marred doors with some type of panel or plate guard on the lower half of the doors, but that repairs depended on available money and the budget. He then accompanied the surveyor to station 2 and observed several of the resident rooms that were in disrepair and in need of repair and maintenance. The Licensed Nursing Home Administrator was later notified of the physical environment concerns involving marred and chipped doors observed on station 2 nursing unit.
Improper Food Storage and Labeling in Kitchen and Nourishment Refrigerator
Penalty
Summary
Sanitation practices were not maintained in the kitchen, service area, and the nursing unit nourishment refrigerator. During the initial tour of the kitchen and service area with the FSD and District Manager, a pair of shoes in a plastic recycle bag and 4 boxes of disposable gloves in a cardboard box were found under a storage rack in the dry storage room on the floor. A personal bag of lunch, including a frozen entrée, was found in the walk-in freezer on the top shelf, and items on both sides of the service hall outside the kitchen included a wheelchair, metal cart, maintenance cart, and 3 cardboard boxes with bottles of chemicals directly on the floor. The FSD removed the shoes, gloves, and personal lunch bag from the kitchen areas during the tour. On the nursing unit nourishment refrigerator and freezer, items were observed stored without required labeling or dating. The refrigerator contained a take-out pizza box, plastic container of fruit, paper bag with food items inside, and a disposable paper bowl with vegetables, all not dated. The freezer contained a large Chick-fil-A milkshake cup with lid full of frozen substance and a large McDonald's plastic cup with straw and lid 1/4 full of frozen substance, both not labeled with resident name and date. The DON stated that food items should be labeled with resident name and date and confirmed that only resident food items were to be stored in the nourishment refrigerator and freezer. The facility policy reviewed by the surveyor stated that food brought in by visitors should be properly maintained, refrigerated items should be monitored daily, and food not for immediate consumption should be properly contained and labeled.
Inconsistent Hand Hygiene During Medication Administration
Penalty
Summary
The infection prevention and control program was deficient because staff did not perform consistent hand hygiene between resident interactions during medication administration. On 03/11/2026 at 7:25 AM, the surveyor observed LPN #19 administering medications to Rooms 121, 122, and 129 and noted that hand hygiene was performed only after leaving one room. On 03/11/26 at 7:36 AM, the surveyor observed LPN #20 administering medications to multiple rooms and noted that hand hygiene was only performed after leaving the rooms. On 03/13/26 at 9:55 AM, the President of Infection Preventionist acknowledged the concerns.
Failure to Notify Resident/Responsible Party of Room Change
Penalty
Summary
Facility staff interviews and surveyor record review identified a failure to provide required notification of a room change to a resident and/or the resident’s responsible party. Record review of a closed medical record for Resident #107, conducted on 3/13/2026, showed that the resident was transferred from room [ROOM NUMBER]-A on station 2 to room [ROOM NUMBER]-B on station 1 on 2/4/2026. The medical record contained no documentation indicating that the resident or the responsible party had been notified of this room change. During an interview on 3/13/2026 at 8:38 AM, the DON was informed by the surveyor that there was no documentation of notification for the room transfer. The DON stated she would look for the room change notification. In a follow-up interview at 9:20 AM the same day, the DON reported she was unable to locate any documentation of notification for the room change, while acknowledging that the facility’s expectation was to notify the resident and/or responsible party of room changes and to document such notifications in the medical record. By the time of survey exit, no information or documentation of notification for Resident #107’s room change had been provided.
Failure to Notify Provider and RP of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the physician and Responsible Party were notified of a resident’s significant change in condition related to weight loss. Resident #6, who had been admitted in May 2025 and was assessed by the attending physician on 6/2/25 as lacking adequate decision-making capacity, lost 18 pounds from 173 pounds on 1/5/26 to 155 pounds on 3/2/26, a 10.4% loss in less than three months. The surveyor also observed the resident declining meals, stating on one occasion that breakfast was not of interest and on another that lunch was not liked, with intake limited to drinks or juices. The record showed that a dietitian documented the weight loss and increased med pass from twice daily to three times daily, with weights changed from monthly to weekly, and noted that the interdisciplinary team was aware and laboratory orders were done per providers. However, the last provider note on 2/20/26 only stated that the resident was eating well and listed a weight of 168 pounds from 2/6/26, with no mention of monitoring the weight loss. Interviews with the dietitian and DON indicated that significant weight loss should be communicated through the weekly risk meeting and documented in a change-of-condition note, but the surveyor found no documentation in the medical record showing that the provider or RP were notified of the resident’s significant weight loss.
Failure to Provide Hearing Services
Penalty
Summary
The facility failed to provide treatment and services to maintain hearing abilities for one resident. Resident #81 was observed tapping the right ear and using a journal at the bedside to communicate with staff, and the roommate reported that staff typically spoke loudly when communicating with the resident. During a later interview, the resident stated that the facility had assessed the hearing well over a month earlier but had not followed up. Record review showed the facility was aware of the resident’s hearing loss, including documentation of unspecified hearing loss, a care plan noting risk for communication problems and poor hearing in the right ear, and an MDS indicating moderate difficulty hearing. The resident was referred by a doctor for newly decreased hearing, evaluated by an audiologist, and found to have moderately severe to profound sensorineural hearing loss in both ears. The audiologist recommended hearing aids for both ears, took impressions, and documented that improved hearing would help the resident hear and understand nursing staff, participate in activities, and be as independent as possible; the note also stated that medical clearance would be needed for the hearing aids.
Failure to Clarify and Document Left Hand Splint Care
Penalty
Summary
Facility staff failed to clarify and document appropriate care measures for Resident #10’s left hand contracture. The resident was observed resting in bed with the left hand contracted, and no splint was applied or visible in the room. The record showed two separate orders for a left hand splint, one directing nursing to apply the splint after morning ADLs and allow removal after about 4 hours while monitoring skin integrity, and another directing nursing to apply a left hand orthotic after ADLs with skin integrity monitoring. However, neither order was entered on the TAR, and there was no documentation of application or removal. The OT discharge summary noted the resident had decreased pain in the left hand/wrist during movement and increased tolerance for the left hand orthotic for more than 4 hours with no redness or irritation. Despite this, the newest splint order was written without the 4-hour limit, and the surveyor found no documentation showing which order was being followed. During interview, the UM stated the splint should be applied for 4 hours a day, initially said it was documented in the TAR, then later stated the order never appeared on the TAR and there was no documentation to demonstrate the splint’s application. The UM also stated there was no clarification as to which of the two orders should be followed.
Failure to Order Recommended Lab Monitoring
Penalty
Summary
The primary medical provider failed to review the resident’s total program of care for one resident reviewed during the survey. The resident had recently been admitted after a hospital stay and reported that the facility was not following the transplant drug regimen correctly. Review of the hospital discharge paperwork showed the resident was discharged to the facility on 2/19/26 with medications ordered as recommended, but the hospital also noted improving and stable renal function and recommended repeat labs, including a BMP in 1 week. The discharge instructions stated that hematocrit and BMP were to be checked weekly on Mondays while at rehab. The provider’s new patient note dated 2/20/25 acknowledged the resident’s transplant and medications, but no laboratory monitoring was mentioned or ordered. When the DON was interviewed, the DON confirmed that the only laboratory order written was for a lab to be drawn on 3/10/26, and the resident had been in the facility for over two weeks without the weekly labs recommended for rehab.
Incorrect Diazepam Dosage and Pharmacy Delivery Failure
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the pharmacy failed to deliver the correct medication dosage for Resident #95. During observation, the surveyor found a discrepancy between the resident’s active Diazepam order and the pharmacy script: the active order directed Diazepam 2 mg, 1.5 tablets by mouth in the morning for anxiety with a hold for sedation instruction, while the script stated 1 tablet by mouth in the morning for anxiety. The bubble packet contained only whole 2 mg tablets. Staff #19 stated that 1.5 tablets were being administered by splitting the available 2 mg Diazepam tablets. A senior pharmacy technician from Pharmscript confirmed that an active script had been sent and received, and reported that the pharmacy was responsible for providing both partial and whole tablets for the resident’s dosage. The technician also stated that the former order had not been picked up by the pharmacy and the new Diazepam had not been delivered to the facility at the time of the survey. The facility’s medication administration policy stated not to split or alter tablets and to contact the pharmacy for the correct dosage, and the controlled substance policy stated that when a prescribed drug is discontinued or a resident is discharged, the container and control sheet must be removed for drug destruction. The resident’s 2 mg Diazepam bubble packet with whole tablets and the corresponding control sheets were still present during medication administration, and the Unit Manager acknowledged the concerns.
Controlled Medication Labeled and Stored Improperly
Penalty
Summary
A controlled medication was not labeled and stored properly for one resident. During a medication administration observation, Staff #19 retrieved a bubble packet for Diazepam 2 mg that was labeled for 1 tablet by mouth in the morning for anxiety, but the medication order in the MAR did not match the packet. The bubble packet reflected an order that had been discontinued on 03/03/26, while the active order started on 03/04/26 and directed Diazepam 2 mg, 1.5 tablets by mouth in the morning for anxiety, with instructions to hold for sedation. Staff #19 confirmed the active order was for 1.5 tablets and stated the dose had already been administered to the resident. The surveyor then observed half a tablet placed back into the resident's previously punctured bubble packet. Staff #19 confirmed that the half tablet of Diazepam was returned to the punctured bubble and stated the resident did not have an updated Diazepam order available. Later, Staff #19 stated that the half tablet of Diazepam that had been returned to the bubble packet was wasted. The Unit Manager acknowledged the concerns.
Delayed Dental Follow-Up and Incomplete Dental Evaluation
Penalty
Summary
The facility failed to ensure that a resident who required dental services on a routine and emergent basis received necessary or recommended dental care in a timely manner. Resident #9 reported still waiting for the facility to follow up on making an appointment for bottom teeth. The resident’s record showed that a dental consult on 9/11/25 documented the resident was seen for a tooth extraction, but could not tolerate the procedure and that the safest course would be extractions under general anesthesia in a hospital setting, with a recommendation for referral to Oral and Maxillofacial Surgery at a local hospital. Subsequent dental notes from the in-house dental provider documented ongoing dental needs, including an initial exam that recommended cleanings every 6 months and a full mouth x-ray to evaluate teeth for extractions and dentures, then a later visit for step 1 dentures that recommended extraction of retained roots for 9 teeth and another full mouth x-ray. On 2/17/26, the resident was seen again for extraction, but x-rays were not taken and a successful extraction could not be guaranteed; the extraction attempts were not successful, and the resident stated he/she had already been referred to the hospital for extraction but there had been no follow-up. The DON later acknowledged that the facility only began pursuing the oral surgery consultation after the 2/17/26 visit and not after the September recommendation, and no documentation was provided showing the requested x-rays had been completed despite several requests.
Food Allergy/Intolerance Not Followed on Meal Tray
Penalty
Summary
The facility failed to ensure that a resident’s food preferences, food intolerances, and food allergies were followed. Resident #41 stated that he/she had a dairy intolerance, but continued to receive dairy products on meal trays. The medical record showed an allergy to dairy products on the physician orders/order summary report, and the Diet History/Food Preferences assessment completed by the Food Services Director also identified a food allergy/intolerance to dairy products. During interview, the Food Services Director stated that Resident #41 had a food preference not to receive dairy products and that this was indicated on the resident’s meal tray tickets. However, the surveyor observed Resident #41 eating breakfast with an 8 oz carton of whole milk on the tray, and the resident stated that milk was not supposed to be on the tray because of the dairy intolerance. The meal tray ticket on the tray also listed Milk - 8 oz, and the Food Services Director later reviewed the ticket and stated it was incorrect and that Resident #41 was not supposed to have milk on the meal ticket or on the meal tray.
Open Dumpster Door Observed Outside Facility
Penalty
Summary
The facility failed to ensure that garbage and refuse were maintained in a proper manner in the outside dumpster area adjacent to the service hall. During the initial tour of the kitchen and dumpster area, surveyors observed that one of the two outside trash dumpsters had its attached lid left open. In an interview, the Food Services Director stated that the dumpster lid should be closed and then closed it. Later, surveyors again observed one of the outside trash dumpster doors open with no staff present in the area. During a subsequent observation with the Maintenance Director, the dumpster door was still open, and the Maintenance Director called out to the Food Services Director, who was outside, to close it. The Maintenance Director stated that staff had recently taken trash to the dumpster and did not close the dumpster door.
Inaccessible Bathroom Call Lights
Penalty
Summary
The facility failed to have call lights accessible in resident bathrooms and bathing areas for 2 of 28 residents reviewed for accessibility of the resident call system. During a tour of station 2 nursing unit on 3/9/2026 at 10:15 AM, the surveyor observed that the pull cord/string attached to the call light device panel next to the toilet in Resident #18's shared bathroom was short in length, and the call light device was not accessible to the resident if he/she was on the floor. Resident #18 was not in the room or bathroom at the time of the observation. Later that same day at 12:30 PM, the surveyor observed that there was no pull cord/string attached to the call light device panel next to the toilet in Resident #75's shared bathroom. Resident #75 was asleep in bed. On 3/11/2026 at 3:15 PM, the Maintenance Director toured the unit with the surveyor and stated that resident bathrooms should have a call light accessible for residents. On 3/13/2026 at 8:15 AM, the surveyor observed that both Resident #18 and Resident #75 had accessible pull cords to the call light device panels in their bathrooms.
Facility Maintenance and Resident Property Security Deficiencies
Penalty
Summary
The facility staff failed to maintain a safe and homelike environment, as evidenced by several maintenance issues observed during an environmental tour. In one room, the baseboard adjacent to a resident's closet was damaged with jagged edges, and the shower room on the 200 unit had ceiling tiles with brown stains and exposed copper pipes protruding from the wall. Additional observations included missing floor tiles, unsecured baseboards, and warped sink countertops in various resident rooms. The Nursing Home Administrator acknowledged awareness of these issues and mentioned a plan for repairs, but no immediate corrective actions were noted. Furthermore, the facility failed to protect a resident's personal property from wandering residents. A resident expressed distress over a broken cell phone charger and missing items, including a notebook, due to other residents entering their room. Despite being aware of the wandering residents, the Director of Nursing and Clinical Director were not informed about the specific incident involving the cell phone charger. The resident, who was alert and oriented, continued to feel unsafe and concerned about the security of their belongings.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility staff failed to protect residents from abuse, as evidenced by two separate incidents involving resident-to-resident interactions. In the first incident, a staff member witnessed a resident undressing and inappropriately touching another resident at their bedside. The staff member immediately intervened by calling for assistance and removing the offending resident from the room. The local police were notified, and the resident was subsequently arrested and did not return to the facility. This incident was identified as a non-compliance sexual abuse concern by the surveyor. In the second incident, facility staff responded to a commotion in a resident's room and found two residents with their arms intertwined. One resident pushed the other, causing them to fall to the floor. Following this incident, the resident who fell was placed on one-to-one observation. The Executive Director acknowledged the surveyor's concern regarding resident-to-resident abuse. Both incidents highlight the facility's failure to maintain a safe environment and protect residents from abuse by other residents.
Failure to Provide Adequate Personal Hygiene Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for two residents who were dependent on staff for assistance with activities of daily living (ADLs). Resident #449, who had an ileostomy, expressed concerns about the care of their ostomy. The resident's care plan, initiated on 11/18/24, indicated a need for assistance with ostomy care. However, the Minimum Data Set (MDS) assessment completed on 10/20/24 documented that the resident was dependent on staff for managing the ostomy. Despite this, the Treatment Administration Record (TAR) for December did not document any ostomy care until 12/5/24, when orders were finally entered. The Director of Nursing confirmed that the ostomy care orders were not entered at the time of admission, and there was no documentation to show that the resident received the necessary care according to their care plan. Resident #68's representative reported that during a visit on 10/28/24, the resident's toenails were unkempt and excessively long. The facility's investigation confirmed that the toenails were addressed after the complaint, and podiatry was consulted. The resident's last podiatry visit was on 4/24/24, where the podiatrist noted that non-professional treatment was hazardous. The MDS assessment conducted on 10/31/24 indicated that the resident was dependent on staff for personal hygiene and required assistance from two or more helpers for putting on and taking off footwear. This lack of timely and adequate care for personal hygiene needs highlights the facility's failure to provide necessary services for dependent residents.
Failure to Provide Adequate Supervision During Incontinent Care
Penalty
Summary
The facility failed to protect a resident from preventable accidents, as evidenced by an incident involving a fall. On December 10, 2023, a resident fell off the bed while a Geriatric Nursing Assistant (GNA) was providing incontinent care. The resident was subsequently evaluated at a hospital, where no injuries or fractures were identified. The resident's Multiple Data Set (MDS) assessment, conducted on September 29, 2023, indicated that the resident was dependent and required two or more helpers for toileting hygiene. However, at the time of the incident, only one GNA was assisting the resident, contrary to the care plan initiated on December 5, 2019, which specified that repositioning should be done with two people, a lifter, or a slider. The Director of Nursing confirmed that only one GNA was involved in the incident.
Inadequate Pain Management for Resident with Baclofen Pump
Penalty
Summary
The facility staff failed to provide appropriate pain management for a resident with an intrathecal baclofen pump, which is used to treat severe spasticity. The resident, who had a history of a traumatic brain injury, quadriplegia, and severe spasticity, was observed with rigid extremities and mild contractions, indicating potential issues with the pump's function. The resident's medical records showed a lack of documentation regarding the assessment and monitoring of the pump's effectiveness and potential complications, such as catheter disconnections or pump dysfunction. Interviews with facility staff revealed that the nursing staff had not received training on the care and monitoring of intrathecal baclofen pumps, leading to a lack of standard care practices. The facility's administration acknowledged the deficiency, noting that they only had information on the next refill date for the pump but lacked details on the combined dosage orders, current pump dosage settings, and battery status. This oversight resulted in inadequate monitoring and management of the resident's pain and spasticity, as well as a failure to ensure the pump's proper functioning.
Failure to Accurately Document and Review Resident's Care Plan
Penalty
Summary
The facility failed to ensure that the medical provider thoroughly reviewed and accurately documented a resident's updated plan of care after a visit. This deficiency was identified for one resident who had been admitted to the facility and subsequently experienced multiple hospitalizations due to medical complications, including mental status changes and a dislodged PEG tube. Upon returning to the facility, the resident's medication orders were not accurately updated to reflect the change from oral administration to PEG tube administration, leading to discrepancies in the medication administration records. The surveyor found that both the Nurse Practitioner and Physician documented that the resident was receiving medications via the oral route, even after the orders had been changed to PEG tube administration. Additionally, the Director of Nursing was unable to confirm the correct route of medication administration, and the Medical Director acknowledged that the oversight regarding the lisinopril administration route may have been an error. This lack of accurate documentation and review of the resident's care plan by the medical providers contributed to the deficiency identified during the survey.
Facility Lacks Effective Pest Control Program for Gnats
Penalty
Summary
The facility failed to ensure an effective pest control program, as evidenced by the presence of flying gnats throughout the building. Surveyors observed gnats in various locations, including a toilet room, near the entrance of a room, and around the nurses' station. The Food Service Director confirmed the presence of gnats in the kitchen, particularly by the floor drains and juice machine, and mentioned that the maintenance department was contacted to address the issue. However, a review of maintenance records for the affected room did not reveal any pest control visits or interventions for gnats. Further investigation into the facility's Pest Control Binder showed numerous reports of gnats in resident care areas from 2017 through 2022, but no documented resolutions to address these reports. The Maintenance Director acknowledged the reports of gnats and stated that a device was used to treat the areas and the pest control company was called in. Despite this, there was no documentation provided to surveyors to demonstrate how the issue was treated or prevented. The Director of Nursing and the Maintenance Director were informed of the survey team's concerns about the lack of documentation and the multiple observations of gnats in the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide a resident with an environment that promotes a dignified existence, as observed in the case of Resident #349. On December 2, 2024, a surveyor observed a clear plastic bag lining the commode in the resident's room, containing a yellow-colored liquid and a piece of toilet paper. When questioned, RN #3 was unsure why the bag was there, suggesting that the resident does things their way. Further inquiry with RN #7 revealed that the bags were initially used to dispose of waste when the resident had a stomach infection, and the practice continued even after the resident was cleared from the infection.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach of a resident, as observed during a recertification survey. On multiple occasions, surveyors found the call bell of Resident #79 on the floor, out of reach. On 12/2/2024, the call bell was observed on the floor next to the resident's bed. This issue persisted, as on 12/4/2024, the call bell was again found on the floor. Geriatric Nursing Assistant #11 confirmed the call bell's location and placed it back within reach. On 12/5/2024, the call bell was once more found on the floor behind the bed. Licensed Practical Nurse #15 acknowledged the expectation that call bells should be within reach and noted the absence of a clip for the call bell. The Registered Nurse Unit Manager confirmed the facility's policy that call bells should always be accessible to residents. The Director of Nursing acknowledged the concerns raised by the surveyors.
Failure to Document Advance Directives and Ensure MOLST Accuracy
Penalty
Summary
The facility staff failed to document whether Resident #32 had an advance directive or wished to formulate one upon admission. The surveyor found no Social History Assessment - Maryland v7 form in Resident #32's medical record, which is where documentation on advance directives was typically found for other residents. During an interview, the Director of Nursing (DON) acknowledged the absence of this documentation and stated that Resident #32 did not have advance directives because the resident was unable to make decisions at the time of admission. No additional information was provided by the DON. For Resident #23, the facility staff did not ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) form. The decision-making section of the MOLST form was left blank, despite the presence of an advance directive on file since 2021. The Director of Nursing and the Administrator confirmed that Doctor staff #24 had completed the MOLST form but failed to check the correct option box, which was an omission. The advance directive had been directing the resident's care decisions since 2021, and the surveyor noted this omission as a concern.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents and/or their representatives upon transfer to an acute care facility. This deficiency was identified for two residents during a survey. In the first case, a resident was transferred to the hospital, and a bed hold was initiated by a unit manager without documented communication with the resident or their representative. The Admissions Director stated that she had reached out to the resident's representative and mailed the policy, but there was no confirmation of receipt or agreement. The discrepancy arose because the nursing staff on the weekend may have incorrectly sent the bed hold document. In the second case, another resident was transferred to the hospital twice, but the representative was only notified of the bed hold policy for the first transfer. The Admissions Director admitted that the policy was not communicated for the second transfer because the resident was only in the emergency room, despite staying overnight. The director acknowledged that she has since been notifying residents and their representatives of the bed hold policy for all hospital transfers, regardless of the duration or nature of the stay.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to accurately document resident assessments on the Minimum Data Set (MDS) for two residents, leading to deficiencies in the accuracy of their medical records. For one resident, who was observed with a colostomy bag, the MDS was inaccurately coded in the Discharge and Medicare/5-day assessments. The coding errors included marking the resident as having no appliances and being always incontinent, despite the presence of a colostomy. The MDS Director acknowledged these inaccuracies during an interview with the surveyor. Another resident's quarterly MDS assessment inaccurately documented the absence of hospice services, despite the resident being on hospice since April 2023. This error was identified during a review of the resident's care plan and MDS assessment. The MDS Director confirmed the mistake and indicated that it was an error in coding. The Executive Director also acknowledged the concern regarding the inaccurate MDS coding.
Failure to Update PASARR After New Diagnosis
Penalty
Summary
The facility failed to initiate a new pre-admission screening and resident review (PASARR) Level I screen after a resident was diagnosed with bipolar disorder while admitted to the nursing facility. Initially, the resident was admitted from an acute care hospital with a PASARR Level I screening completed, which did not identify the need for a Level II evaluation. However, during the resident's stay, a diagnosis of bipolar disorder was added, which should have triggered a new PASARR Level I screening to determine if a Level II evaluation was necessary. The deficiency was identified during a recertification survey, where it was noted that the resident's medical record showed the diagnosis of bipolar disorder was added after admission. The facility's Admissions Director acknowledged that a new PASARR Level I should have been conducted following the updated diagnosis. The Executive Director also recognized the issue, indicating that there is now a process in place to update PASARRs when new mental disorder or intellectual disorder diagnoses are identified during a resident's stay.
Failure to Include Dietary Needs in Baseline Care Plan
Penalty
Summary
The facility failed to include all necessary initial healthcare information in the baseline care plan for a resident within 48 hours of admission. Specifically, the baseline care plan for a resident with a medical history of congestive heart failure, atrial fibrillation, malaise, digestive system disease, and dementia did not address the resident's dietary and nutritional needs. This omission was identified during a review of the resident's medical records and care plans, which showed that while other care plans were initiated shortly after admission, the dietary and nutritional care plan was not included in the baseline care plan. Interviews with facility staff, including the Director of Nursing, MDS staff, and the Nursing Home Administrator, revealed that the baseline care plan is typically initiated by the nurse manager and supplemented by MDS staff based on further assessments. The facility's policy requires that the baseline care plan, also known as the 48-hour care plan, address physician and dietary orders. However, in this case, the baseline care plan did not include a care plan for diet/nutrition, despite the resident's comprehensive care plan indicating a need for a special diet with supervisory intervention.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident #94, admitted in October 2024, had a history of urinary retention and was observed with an indwelling urinary device, yet lacked a corresponding care plan. Additionally, the care plan for Activities of Daily Living (ADLs) was improperly developed, indicating multiple dependency levels instead of a single level of support. Interviews with the Director of Nursing (DON) and MDS staff confirmed these oversights, acknowledging errors in the support assessment and the absence of a care plan for the urinary device. Resident #77 was found to have a missing lens in their glasses, which had been reported to staff months prior, yet no action was taken to address this issue or schedule an ophthalmologist appointment. The resident's care plan lacked any focus on vision or accessibility to glasses. Similarly, Resident #42, who was admitted with a colostomy, did not have a care plan addressing colostomy care and services. Interviews with the DON and RN Unit Manager confirmed the absence of a care plan for the colostomy, despite the resident's needs.
Failure to Update Care Plan Post-Readmission
Penalty
Summary
The facility failed to update and revise the care plan for a resident following their readmission. The resident, who was initially admitted on October 8, 2024, and discharged to the hospital on October 27, 2024, was readmitted on November 3, 2024. Despite having physician orders for Apixaban for DVT and Clonazepam for anxiety, the care plan was not revised to reflect the usage and monitoring of these medications after the resident's readmission. The Director of Nursing confirmed that the resident had two separate care plans: one that was closed upon discharge to the hospital and another initiated upon readmission. However, the new care plan did not include updates or revisions for the anticoagulant and antianxiety medications, which were present in the original care plan. This oversight was identified during a record review conducted by the surveyor on December 5, 2024.
Failure to Administer and Document Care as Ordered
Penalty
Summary
The facility failed to provide treatments according to the care plan for two residents. Resident #71, who had a care plan for constipation due to decreased mobility, did not receive the prescribed as-needed medications for constipation despite not having a bowel movement for several days. The resident's care plan included the administration of Senna, Miralax, and as-needed Dulcolax suppository and fleet enema. However, the Medication Administration Record showed that these as-needed medications were not administered, and there was no documentation of bowel movements for several days. The Director of Nursing confirmed the lack of documentation and the failure to administer the medications as ordered. Resident #94, who had a history of urinary retention, was observed with a urinary bag but lacked documentation of urinary output as required by the physician's order. The order specified that foley catheter care and documentation of output should occur every shift. However, the Treatment Administration Record and point of care documentation showed no recorded urinary output. The Director of Nursing acknowledged the failure to document the urinary output according to the physician's order.
Failure to Coordinate Vision Services for a Resident
Penalty
Summary
The facility failed to coordinate vision services for a resident, as evidenced by the case of Resident #77. During an observation and interview, it was noted that the resident had been missing a lens from their glasses for months and had informed the staff, but no follow-up occurred. The resident also reported not having seen an ophthalmologist since their admission to the facility. A review of the resident's records showed that a consult for various services, including optometry and ophthalmology, was ordered months prior, but the resident had not been seen by an ophthalmologist. An interview with the Director of Nursing confirmed that the resident had not received ophthalmology services since admission, and the missing lens issue had not been addressed.
Lack of Physician Order for Colostomy Care
Penalty
Summary
The facility failed to provide adequate care and services for a resident requiring colostomy care. During an observation, the surveyor noted that the resident had a colostomy bag on the abdomen. However, upon reviewing the resident's medical records, it was discovered that there was no physician order for the care of the colostomy. This lack of documentation was confirmed during an interview with the RN Unit Manager, who acknowledged that the resident was admitted with a colostomy but did not have a corresponding physician order for its care. Further investigation revealed that the Director of Nursing, along with the Nursing Home Administrator, was informed of the deficiency. The Director of Nursing confirmed the absence of a physician order for colostomy care for the resident. This oversight was only addressed after the surveyor's intervention, highlighting a lapse in the facility's protocol for managing residents with specific medical needs such as colostomy care.
Failure to Maintain Oxygen Safety Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident who required continuous oxygen therapy. During a tour of Unit 200, the surveyor observed that the resident was using oxygen but there was no 'oxygen in use - no smoking' signage posted on the resident's room door. This observation was made on multiple occasions, including on 12/2/2024, 12/4/2024, and 12/6/2024. The absence of the required signage was confirmed through interviews with the RN Unit Manager, who acknowledged that the signage should be posted on the resident's room door or doorframe. The resident's medical record review revealed a physician's order for continuous oxygen and a care plan intervention for oxygen therapy, which had been documented as being used every shift daily since 11/1/2024. Despite this, the necessary safety signage was not maintained, indicating a lapse in the facility's adherence to safety protocols for residents receiving oxygen therapy. The RN Unit Manager suggested that the signage might have fallen off, but this does not mitigate the facility's responsibility to ensure proper safety measures are consistently in place.
Medication Regimen Deficiencies
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs, as evidenced by the cases of two residents. For the first resident, there was a duplication in the administration of sodium chloride. The resident was initially prescribed sodium chloride 1 gram to be given three times a day, and on a subsequent date, a new order for sodium chloride 2 grams daily was written. Both orders were administered on the same day before the original order was discontinued, resulting in an unnecessary duplication of medication. The resident's primary care physician confirmed that such duplication is not standard practice and indicated that the nurse practitioner involved would be educated on avoiding duplicate orders. In the second case, a resident returned to the facility with a PEG tube after hospitalization. Upon return, levofloxacin was ordered and administered via the oral route, despite the hospital discharge summary indicating that the medication should be stopped. The order was later changed to the PEG tube route and then discontinued shortly after. This indicates a failure to update the resident's medication orders according to the current plan of care, as noted by the surveyor during an interview with the Director of Nursing.
Failure to Coordinate Routine Dental Services
Penalty
Summary
The facility failed to coordinate routine dental services for a resident, as evidenced by the case of Resident #68. The resident's representative observed the resident's teeth were black during a visit on 10/28/24, raising concerns about the resident's dental care. A complaint was filed regarding the resident's dental care and appointments. A review of the resident's orders showed that a dental consult was ordered on 8/28/23, and the resident was last seen by the Dental Group on 10/30/23. The dental note from that visit recommended the resident be seen every six months for cleaning, with the next appointment scheduled for 10/30/24. However, the Director of Nursing stated that specialty care groups are responsible for following up with recommendations and scheduling appointments, indicating a lack of coordination in ensuring the resident received timely dental care.
Incomplete Resident Record Documentation
Penalty
Summary
The facility failed to maintain accurate resident records in accordance with professional standards, as evidenced by the case of Resident #54. On December 1, 2024, Resident #54 was transferred to the hospital, and the transfer form included a section for Resident Representative Notification. Although the date and time of notification were recorded, the name of the representative was left blank. During an interview, LPN Staff #27 confirmed that she had notified the resident's representative but did not lock the note until December 3, 2024, which resulted in incomplete information in the medical record. The Director of Nursing acknowledged the concern that unlocked notes lead to missing information and incomplete records.
Improper Waste Disposal Practices
Penalty
Summary
The facility failed to adhere to proper infection control practices in handling a resident's waste. During an observation, a clear plastic bag was found lining the commode in a resident's room, containing a yellow-colored liquid and a piece of toilet paper. A registered nurse was unsure why the bag was used, attributing it to the resident's personal habits. Another nurse explained that the bags were initially used when the resident had a stomach infection, but continued to be used even after the infection was cleared. The nurse was unable to explain how the waste was disposed of and sought clarification from the Director of Nursing, who stated that waste should be disposed of in biohazard bags and that all staff should be aware of this procedure.
Failure to Obtain Immunization Consent from Resident's Representative
Penalty
Summary
The facility failed to notify and obtain consent from a resident's representative for immunizations, as identified during a recertification survey. Specifically, Resident #92, who had a BIMS score of 00 indicating severe cognitive impairment, had verbal declinations for influenza and pneumococcal vaccinations signed by the facility's Infection Preventionist (IP) without consulting the resident's representative. The resident's medical records indicated a designated representative, but there was no documentation that this representative was contacted regarding the resident's verbal declination of immunizations. During an interview, the facility's IP confirmed that for residents lacking capacity to make their own medical decisions, the representative should be consulted, and acknowledged the absence of such documentation for Resident #92. The Executive Director also acknowledged the surveyors' concerns about the lack of contact with the resident's representative. This oversight was later rectified when the representative was contacted and consent was obtained, but the initial failure to follow proper procedures led to the deficiency.
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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