St. Elizabeth Rehabilitation & Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 3320 Benson Avenue, Baltimore, Maryland 21227
- CMS Provider Number
- 215044
- Inspections on file
- 18
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 35
Citation history
Health deficiencies cited at St. Elizabeth Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
Unlabeled and undated refrigerated food items were observed in kitchen storage, including cabbage, carrots, mixed vegetables, sliced tomatoes, and tuna fish. Staff acknowledged that some items should have been dated and that some past-dated food had been overlooked. The CDM later confirmed additional unlabeled items during a follow-up kitchen tour.
A facility failed to provide respiratory care that matched physician orders for multiple residents receiving O2. One resident was found on nasal cannula O2 without an active order for flow rate, and staff relied on shift report rather than verifying the EHR, resulting in incorrect flow settings. Other residents had O2 tubing that was not dated or labeled as expected, and one resident’s O2 was set below the ordered rate until staff adjusted it after observation.
Food Served at Improper Temperature During Meal Delivery: A resident reported that food was consistently cold when delivered to the room, and another resident said meals were cold and stale upon delivery. During tray line observation, staff prepared room trays only after dining room service was completed, and a test tray delivered to a resident room showed hot items below the facility’s expected temperature range. The CDM acknowledged the concern when the temperatures were checked.
Failure to Document Hospital Transfer Notices and Bed-Hold Information: The facility did not ensure that written notice of hospital transfer and bed-hold policy information were documented for two residents who were transferred to the hospital. One resident had anemia and altered mental status, and another had acute respiratory failure with hypoxia and repeated hospitalizations for pneumonia and hypoxia. The DON stated that family notification and bed-hold completion were part of the process, but no documentation was available for either resident.
A resident receiving oxygen therapy had an active physician order for oxygen, but the comprehensive care plan did not include any goals or interventions for oxygen administration, monitoring, or safety precautions. The DON stated that residents on oxygen were expected to have this addressed in the care plan.
A resident's pain was assessed on the TAR, but the required progress notes were not found in the chart. The DON stated staff were expected to assess pain and document it in a progress note per the physician's order, but she could not locate any pain progress notes and acknowledged they should have been present.
Meals were not consistently served according to the posted menu or resident preferences. A resident received food that did not match the meal ticket, another resident reported pre-ordered meals were often unavailable, and a third resident was served an alternate potato instead of the baked sweet potato listed. The CDM acknowledged that the kitchen served what was available when the ordered item was not ready and that residents were not informed of the delay or offered another choice.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe cognitive and physical impairments, who required staff assistance for mobility, was injured after falling from a wheelchair that lacked leg rests during staff transport. The absence of leg rests, contrary to facility policy, allowed the resident's feet to become caught under the wheelchair, resulting in a forward fall and head injury. The facility did not complete a full investigation or root cause analysis following the incident.
Staff failed to respond to resident call bells within the facility's required timeframe, with numerous instances of delays exceeding 30 minutes and some over an hour. Additionally, a resident with a PEG tube did not receive prescribed site care, as the order was not documented on the TAR or MAR, and care was not provided as directed by the physician.
Facility staff did not determine if a resident had an advance directive upon admission, nor did they provide information or assistance regarding advance directives. Later, after the resident was found to lack decision-making capacity, the facility failed to document or identify a surrogate decision maker.
A resident with a history of blood clots was lowered to the floor by staff, who did not report the incident as a fall. The resident later exhibited swelling and inability to bear weight, leading to hospital transfer and diagnosis of a hip fracture. The responsible party was not notified of the incident until the resident was hospitalized.
A resident who was admitted for therapy and antibiotics did not receive assistance with changing out of a soiled brief during a night shift, leading the family to file a grievance alleging neglect by a GNA. Although the staff member was terminated, there was no documented follow-up with the resident or family, and the resident remained distressed and uncertain about the situation. The facility's grievance policy requires keeping residents informed and providing a written decision, but these steps were not documented.
Staff failed to promptly report incidents of suspected abuse and neglect, including not documenting or notifying responsible parties after a resident was lowered to the floor and later found with a hip fracture, and not reporting allegations of sexual abuse and neglect to authorities within required timeframes. In some cases, staff did not immediately escalate residents' distress or unusual behavior to supervisors, resulting in delayed investigations and notifications.
Facility staff did not conduct thorough investigations into allegations of abuse and neglect, including failing to perform timely physical assessments, interview other potentially affected residents, or ensure accurate documentation of care. In several cases, residents with cognitive impairment or those unable to be interviewed were not properly assessed, and staff statements lacked necessary details, resulting in incomplete investigations.
A resident's cognitive status was not accurately assessed on the MDS due to a documentation error, where another resident's information was entered under the wrong record. The BIMS section was left unassessed or unrated in all submitted MDS assessments, despite the resident being cognitively intact at admission.
Surveyors found that the facility did not develop individualized, measurable care plans for two residents with complex medical and psychiatric needs. One resident with multiple diagnoses and a PEG tube lacked a care plan addressing specific interventions for each condition, NPO status, and oral care needs. Another resident with psychiatric diagnoses had no care plan or interventions documented. These deficiencies were confirmed through record review and staff interviews.
A resident with bowel and bladder incontinence was not consistently changed and cleaned by nursing staff, as shown by documentation gaps across multiple shifts and days. The DON and Administrator confirmed that agency GNAs were unaware of proper documentation procedures. During a facility tour, a strong urine odor was noted and a resident complained about delays in being changed, with no response from the Administrator.
A resident who required maximal assistance for bathing did not receive scheduled showers for an extended period, with records indicating no showers were provided during one month and only two showers in nearly two months. The DON was unable to locate documentation to account for missed showers.
A resident who was dependent on staff for feeding experienced a significant decrease in oral intake over several days, with missed meals and no updated nutritional assessment. Facility staff did not alert the dietitian or reassess the resident despite documented reduced intake. The resident's condition worsened, leading to hospitalization for dehydration after staff were unable to establish IV access and reported decreased intake to the hospital.
Staff failed to maintain a complete and accurate medical record for a resident, as documentation of a physician-ordered PT evaluation for wheelchair and positioning was missing. Interviews with the PT Director and DON confirmed the absence of required information in the electronic medical record.
A resident with vascular dementia and impaired mobility eloped from a secure unit due to inadequate supervision and an unsecured gate. The resident left during an outdoor activity when the staff was assisting another resident, and the gate was left unlocked after a fire drill. The resident was found at a nearby hospital and returned without injuries.
The facility failed to maintain clean carpets, with surveyors observing sticky carpets in several rooms. The Maintenance Director attributed the issue to improper cleaning solution ratios. Numerous work orders for carpet cleaning were noted, and complaints about dirty carpets dated back to 2023. The NHA acknowledged the problem and mentioned plans for carpet replacement.
The facility failed to report the results of abuse investigations within the required five working days for four residents. An alleged abuse incident involving a resident occurred, and the final report was submitted late. Additionally, three residents alleged abuse by a GNA, and the final report was also submitted late. The DON confirmed awareness of the delays.
A facility failed to inform a resident about a new medication, Semaglutide, prescribed for diabetes control. Despite the resident being their own healthcare decision-maker and having a history of congestive heart failure, hypertension, and other conditions, there was no documentation that they were informed about the medication or its side effects. This deficiency was noted during a review of medical records and interviews.
The facility failed to protect residents from abuse, as one resident was observed hitting another in the face, and later kicked a different resident. The aggressor had adjustment problems and involuntary movements due to their condition. Despite being sent for psychiatric care, the facility could not relocate the aggressor until behavior management was achieved, leading to a failure in protecting residents.
A facility failed to suspend a GNA during an abuse investigation involving a resident who alleged being beaten by staff. The investigation could not substantiate the claim, but the GNA was only reassigned, not suspended. The DON admitted the GNA should have been suspended until the investigation concluded.
A resident discharged from a facility with planned home health services experienced a delay in receiving care due to incomplete documentation. The interdisciplinary team discharge form indicated the need for various home health services, but the home health agency required clearer documentation to start services. Despite efforts by the social worker and communication with the nursing home administrator, the necessary documentation was delayed, resulting in an eight-day gap before services began.
A resident with dementia and mobility issues was left unsupervised in the shower, resulting in a fall due to a broken chair. The care plan required staff assistance during bathing, which was not provided. Another resident with multiple medical conditions had incomplete documentation of wound care treatments, indicating potential lapses in care. The DON acknowledged the lack of supervision and unexplained missing documentation.
A facility failed to maintain resident privacy and dignity during medication administration. An RN was observed not closing the door or drawing the room divider curtain while assessing and treating residents. The RN acknowledged the oversight, stating awareness of the facility's privacy policy.
The facility did not notify the local Ombudsman of a resident's transfer to the hospital, as required. A resident was transferred to the emergency room for evaluation and treatment, but this discharge was not included in the report to the Ombudsman. The DON confirmed that the facility was not sending the Ombudsman copies of transfer or discharge notices.
A facility failed to accurately code a resident's behavioral symptoms on the MDS, despite documentation showing behaviors in the 7-day look-back period. The MDS Coordinator acknowledged the error after review.
A facility failed to maintain good personal hygiene for a dependent resident. A surveyor observed the resident in an incontinence brief, and records showed they received only four showers and one bed bath in 24 days, contrary to the facility's policy of twice-weekly showers. The NHA confirmed the discrepancy.
The facility did not update nurse staffing information daily, as observed on two occasions when the posted data was outdated. The Staffing Coordinator, responsible for posting, did not work weekends, and the nursing supervisor was tasked with updates during that time. The NHA was informed of the issue.
The facility failed to ensure that an account of all controlled drugs was completed, as 6 out of 14 Controlled Medication Shift Change Logs showed incomplete counts for 31 shifts. The policy requires incoming and outgoing nurses to count all controlled medications, a practice not followed, as confirmed by an LPN and the DON.
The facility was found deficient in securing medication carts and properly storing medications. Three medication carts were left unlocked and unattended, containing improperly labeled insulin pens. Additionally, two medication storage rooms had improperly stored and expired medications. Staff interviews confirmed these practices did not meet facility expectations.
A facility failed to ensure accurate entry of resident information for lab specimens, leading to the rejection of samples due to incorrect DOB entries. A resident's blood and stool samples were canceled by an outside lab because of this error, which was confirmed by the DON. The issue was systemic, as both samples obtained by the outside lab and the facility's nurse were affected.
The facility failed to properly store and label food, with surveyors finding undated and improperly wrapped items in the freezer, expired bologna in the refrigerator, and unlabeled food in the dining room. The Certified Dietary Manager acknowledged these issues, which contravened facility policy.
A facility failed to sanitize medical equipment between residents, as observed with an RN using a blood pressure cuff and monitor on multiple residents without cleaning them between uses. The RN acknowledged the oversight and confirmed that the facility's protocol required sanitization of shared equipment after each use.
The facility failed to notify responsible parties of medication changes for three residents, despite evaluations indicating the need for such notifications. This included changes in medications like Semaglutide, Aricept, and Remeron, without informing the designated health care agents or family members.
The facility failed to respond to call bells promptly, affecting the care of multiple residents. One resident reported waiting over an hour for assistance, while another experienced a delay of hours for incontinent care. Call history reports confirmed multiple instances of excessive wait times, with staff not having pagers during some incidents. Additionally, a resident experienced a significant delay in response to a call light, coinciding with a medical emergency that required hospitalization. The NHA acknowledged the unacceptable response times.
Unlabeled and Undated Refrigerated Food Items
Penalty
Summary
The facility failed to ensure that refrigerated food items were consistently labeled and dated with preparation and expiration dates in the kitchen storage areas. During the initial kitchen tour, surveyors observed eight bags of cabbage without labels or dates, one mixed tray of carrots and cabbage that was unlabeled and undated, two trays of sliced tomatoes without labels or dates, and two bags of carrots marked with a Best Used By date of January 27, 2026. The Dietary Technician stated that unlabeled groceries were usually prepared the same day or the day before and acknowledged that they should have been dated. He also stated that the cabbage was supposed to have an expiration date and that the past-dated carrots were an oversight. During a follow-up kitchen visit, surveyors again observed two unlabeled and undated bags of carrots in the grocery refrigerator, along with two trays of tuna fish and one tray of sliced tomatoes stored in another refrigerator without labels or dates. The Certified Dietary Manager acknowledged the findings. The Director of Nursing and the Nursing Home Administrator were later informed of the concerns identified during the kitchen tours and acknowledged the findings.
Respiratory Care Orders and Oxygen Equipment Not Properly Managed
Penalty
Summary
The facility failed to provide respiratory care services that met professional standards for multiple residents receiving oxygen therapy. Resident #161 was observed receiving oxygen via nasal cannula, but the electronic health record initially contained no active physician order for oxygen therapy or an oxygen flow rate. The record did include an order for changing oxygen tubing and humidifier bottles weekly and as needed, and the hospital discharge summary showed the resident had been discharged on 3 LPM of oxygen. Staff interviews showed that one LPN believed the resident was on 2 LPM based on shift report, while the EHR did not contain an oxygen order at that time. During a dual observation, Resident #161’s oxygen concentrator was found set at 4.5 LPM and was adjusted to 2 LPM by an LPN. Later, after a physician order for 3 LPM via nasal cannula was entered, the resident was again observed with the concentrator set at 4 LPM. An RN stated she had been told during shift report that the resident was to receive 4 LPM, but after reviewing the EHR she confirmed the order was for 3 LPM and adjusted the oxygen to that rate. The Unit Manager stated the error involved inaccurate shift reporting and failure of incoming nurses to verify physician orders. Other residents had similar respiratory care issues. Resident #118 and Resident #160 were observed receiving oxygen via nasal cannula with tubing that was not dated or labeled on repeated observations, and staff confirmed the tubing should have been labeled and dated after being changed. Resident #2 was observed with oxygen set at 2 liters when the resident stated it should be 3 liters, and staff adjusted it to 3 liters after the resident’s statement. Resident #2’s oxygen tubing was also observed unlabeled on two occasions before later being found labeled. The report also identified these respiratory care concerns as affecting 6 of 9 residents reviewed for respiratory services.
Food Served at Improper Temperature During Meal Delivery
Penalty
Summary
The facility failed to ensure that food was served to residents at an appropriate and palatable temperature. During interviews, Resident #63 reported that food was consistently cold when delivered to the room, and Resident #92 stated that meals were cold and stale upon delivery. These resident statements were made in the context of room service meal delivery and reflected concerns about the temperature and condition of the food when received. During observation of the lunch tray line and meal delivery process, the surveyor saw Dietary Aide Staff #19 plating meals for residents eating in the main dining room and stating that trays for residents who preferred to dine in their rooms would not be prepared until after dining room meal service was completed. The first meal cart left the dining room at 11:52 AM, and the final cart departed at 12:41 PM. The surveyor requested a test tray be placed on the final cart for the first floor, and the tray was delivered to a resident room at 12:49 PM. When the CDM checked the test tray at 12:50 PM, the recorded temperatures were 72.2 F for peanut butter pie, 104.4 F for cola-glazed ham, 113 F for baked sweet potato, 116 F for green beans, and 117 F for carrots. The CDM stated that hot foods were required to be served between 125 F and 135 F and cold foods at 41 F or below, and acknowledged the concern when informed of the temperatures.
Failure to Document Hospital Transfer Notices and Bed-Hold Information
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were provided written notice of hospital transfer and information regarding the facility’s bed-hold policy for 2 residents reviewed for hospitalization. Resident #14 was transferred to the hospital with diagnoses of anemia and altered mental status, but the clinical record did not contain documentation of a notice of transfer. Resident #5 was discharged to the hospital due to acute respiratory failure with hypoxia, with documentation also noting repeated hospitalizations for pneumonia and hypoxia, but the record contained no documentation of a notice of transfer or disclosure of the bed-hold policy. During interview, the DON stated that when a resident is transferred to the hospital, the facility obtains a physician order, completes e-Interact/SBAR documentation, and notifies the family. The DON also stated that a bed hold is completed for every hospital transfer and that the family is notified. When asked to provide documentation for Residents #5 and #14, the DON stated that no documentation of the notice of transfer or bed-hold policy was available for Resident #5 and no documentation of notice of transfer was available for Resident #14, and acknowledged the concern.
Failure to Include Oxygen Therapy in the Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and/or update the comprehensive care plan to include oxygen therapy for Resident #2, who was observed receiving oxygen therapy during the survey. Record review showed an active physician's order for oxygen, but the comprehensive care plan contained no goals or interventions addressing oxygen therapy, including administration, monitoring, or safety precautions. The deficiency was identified during the annual survey based on observations, record review, and interview, and the Director of Nursing stated that residents receiving oxygen therapy were expected to have this addressed in the comprehensive care plan.
Missing Pain Assessment Documentation
Penalty
Summary
The facility failed to accurately and completely document a resident's pain as ordered by the physician. For Resident #119, the medical record included an order stating, "Has the elder experienced pain during the last 8 hours. If yes, complete a progress note," and the TAR for January and February 2026 included the same pain assessment task. Review of the TAR showed several assessments indicating the resident had pain, but a review of the progress notes found no documentation related to the resident's pain assessment. During interviews, the DON stated that nursing staff were expected to assess the resident for pain and document the pain assessment in a progress note per the physician's order, but she was unable to locate any pain progress notes and acknowledged that there should have been progress notes related to the resident's pain assessment because the order required them.
Meals Served Did Not Match Menu or Resident Preferences
Penalty
Summary
The facility failed to ensure residents were served meals according to the predetermined menu and resident preferences. During the survey, Resident #2 stated that the meal served did not match the meal ticket; the surveyor observed a hard-boiled egg, ham, and bread on the resident’s plate, while the ticket listed juice, oatmeal, scrambled eggs, bacon, a cranberry orange muffin, fruit, milk, and coffee. Resident #63 also reported not receiving pre-ordered meals because the ordered meals were unavailable, and stated this had been occurring for a while. During a lunch observation, the menu listed potato-crusted fish with rice pilaf, seasoned greens, a roll with margarine, and chocolate cake with frosting, with Salisbury steak as the alternate entree. Resident #63 requested the rice pilaf meal but was served mashed potatoes, carrots, peas, and a bread roll instead, and stated the cake with frosting was not served. Resident #2 later stated an alternate tray of Salisbury steak with gravy, mashed potatoes with gravy, and vegetables had been provided, but the resident returned it because of a preference not to have gravy. Resident #163 was observed with a regular potato, cornbread, carrots, peas, peanut butter pie, and a beverage, although the meal ticket listed cola-glazed ham, a baked sweet potato, Italian blend vegetables, cornbread with margarine, peanut butter pie, and a beverage. The Certified Dietary Manager stated sweet potatoes were available but remained in the oven at lunchtime, so regular potatoes were served, and acknowledged residents were not informed of the delay or offered an alternative choice.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Prevent Avoidable Fall Due to Missing Wheelchair Leg Rests
Penalty
Summary
A deficiency was identified when a resident with dementia, polyarthritis, muscle contracture, and severe cognitive impairment experienced a fall resulting in actual harm. The resident was dependent on staff for activities of daily living, including mobility and personal care. The care plan indicated the need for staff assistance and escort to activities. On the day of the incident, the resident was being pushed in a wheelchair by a GNA after breakfast, when the resident fell forward from the wheelchair, sustaining a laceration to the forehead and requiring hospital evaluation. The medical record and staff interviews confirmed that the wheelchair did not have leg rests attached at the time of transport, contrary to facility policy and staff expectations for safe resident transport. Further review revealed that the facility did not complete a summary of the investigation, witness statements, or a root cause analysis for the fall. Interviews with the Director of PT and the DON confirmed the requirement for leg rests when staff transport residents in wheelchairs, but neither could recall the specific incident. The GNA involved could not remember if leg rests were in place and reported that the resident's feet went under the wheelchair, causing the fall. The lack of proper wheelchair equipment and supervision directly contributed to the resident's avoidable fall and subsequent injury.
Failure to Respond Timely to Call Bells and Provide PEG Tube Site Care
Penalty
Summary
Facility staff failed to provide timely responses to resident call bells and did not ensure proper gastrostomy tube (PEG) site care for a resident. Review of call bell logs over a one-week period revealed 114 instances where call bells were left unanswered for more than 30 minutes, with 31 of those occasions exceeding one hour. The facility's policy required all staff to respond to call lights within a reasonable timeframe, defined by the DON as within 15 minutes, or up to 25 minutes if staff were with another resident. Despite this policy, staff did not consistently meet these expectations, and the facility was unable to demonstrate effective monitoring or identification of trends related to call bell response times. Additionally, a resident with a PEG tube did not receive documented site care as ordered by the physician. The order to cleanse the PEG tube site with soap and water and cover with dry gauze every night shift was not transcribed onto the Treatment Administration Record (TAR) or Medication Administration Record (MAR) for July or August, and no new order was written upon the resident's return from the hospital. Interviews with nursing leadership confirmed that PEG tube care should have been documented and performed according to physician orders, but this was not done, resulting in the resident's PEG tube site being left uncleaned on multiple occasions.
Failure to Determine Advance Directive Status and Identify Decision Maker
Penalty
Summary
Facility staff failed to determine on admission whether a resident had an advance directive and did not provide information about the right to formulate one. The admission record for the resident showed the section for advance directives was left blank, and there was no documentation indicating that staff had informed the resident of their rights or offered assistance in establishing an advance directive. The resident was noted as being cognitively intact at admission, with a BIMS score of 14, and was listed as their own responsible party. Subsequently, the resident experienced increased confusion and was assessed by two physicians, who determined that the resident lacked capacity to make informed medical decisions. Despite this change in condition, the medical record did not identify who was responsible for making decisions on the resident's behalf or how a surrogate decision maker was determined. When requested, the facility administrator was unable to provide documentation regarding advance directives or the identification of a decision maker for the resident.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to notify the responsible party after a resident experienced a fall. On 8/23/24, a staff member lowered the resident to the floor, but did not consider this a fall and therefore did not report the incident. The resident, who had a history of blood clots, was later observed by a family member to have a swollen left ankle and was unable to stand or put pressure on the foot. Medical assessments, including an x-ray and venous doppler, were performed, and the resident was eventually sent to the hospital where a left hip fracture was diagnosed and surgically repaired. The responsible party was not informed of the fall until several days later, when the resident was already at the hospital.
Failure to Provide Adequate Grievance Follow-Up After Alleged Neglect
Penalty
Summary
A resident was admitted to the facility for therapy and antibiotics. On a night shift, the resident repeatedly used the call-light to request assistance with changing out of a soiled brief, but did not receive help. The resident's family submitted a grievance alleging that a GNA failed to provide any activities of daily living during that shift. The grievance form indicated that the employee was terminated, but there was no documentation of follow-up with the resident or family regarding the resolution of the grievance. During an interview, the resident expressed ongoing distress and fear, stating they had not received any follow-up and were unsure if the staff member involved would return. The DON stated that follow-up had occurred, but was unable to provide documentation to support this. Review of the facility's grievance policy showed requirements for keeping residents informed of progress and issuing a written decision at the conclusion of the investigation, but these steps were not documented in this case.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
Facility staff failed to report incidents of suspected abuse, neglect, or theft within required timeframes for multiple residents. In one case, a resident was lowered to the floor by a staff member, but the incident was not documented or reported as a fall. The resident's responsible party was not notified until the resident was sent to the hospital days later with a hip fracture. There were no nursing notes or investigation conducted immediately after the incident, and the staff member involved did not report the event, believing it did not constitute a fall. In another instance, a resident reported possible sexual abuse to a family member, who then informed facility staff. However, the facility did not report the allegation to the state agency within the mandated two-hour window after becoming aware of it. Additional deficiencies included a delay in reporting an allegation of neglect involving another resident, where the facility was aware of the situation but did not notify the state agency until several days later, following a formal grievance by the family. In a separate case, a staff member observed a resident in distress and exhibiting unusual behavior suggestive of possible abuse but did not immediately report this to a nurse or supervisor. The facility's investigation later noted that such behavior was considered baseline for the resident, but there was no evidence of timely reporting or documentation at the time of the incident.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of abuse and neglect involving multiple residents. In one case, a moderately cognitively impaired resident residing on a memory care unit reported a possible sexual abuse incident to a family member, which was then reported to facility staff. Although the facility's investigation included interviews with the resident, family, and staff, there was no evidence that a physical assessment was conducted at the time the allegation was reported. Additionally, no interviews were conducted with other residents on the same unit, nor were assessments completed for other vulnerable residents who may have been affected. In another incident, the DON was made aware of an allegation of neglect involving a resident found in a soiled brief with sacral excoriation. The ADON took a photograph and applied a moisture barrier cream, but there was no documented skin assessment of the excoriation. Further review revealed that the GNA responsible for the resident had documented care for several other residents during the same shift, despite evidence that care was not provided, and similar documentation patterns were found over three consecutive days. The DON and NHA were unaware of the extent of inaccurate documentation and lack of care provided by the GNA. A third incident involved an allegation of physical abuse reported by a resident's family member. The facility's investigation included staff statements, but most did not specify the relevant date or shift, and statements were missing from several staff who worked during the period in question. Of the 32-33 residents on the unit, only four were interviewed, and there were no physical assessments for residents who could not be interviewed. These deficiencies in the investigative process were acknowledged by facility leadership during interviews with surveyors.
Failure to Accurately Complete BIMS Assessment on MDS
Penalty
Summary
The facility failed to complete accurate assessments for a resident regarding the Brief Interview of Mental Status (BIMS) as part of the federally mandated Minimum Data Set (MDS) process. Medical record review showed that upon admission, the resident was identified as their own representative and was able to sign the admission contract. The social worker completed a BIMS assessment at admission, with the resident scoring a 13, indicating cognitive intactness. However, subsequent reviews of the resident's medical record revealed that all submitted MDS assessments for cognitive status since admission did not include the BIMS score, and the section was either not assessed or not rated as required. During an interview, the social worker responsible for completing the BIMS and MDS assessments was unable to recall the details and needed to review her notes. Upon follow-up, the social worker acknowledged an error in documentation, stating that another resident's information was entered under this resident, resulting in inaccurate MDS submissions for the BIMS section. This documentation error led to the failure to ensure an accurate assessment of the resident's cognitive status.
Failure to Develop Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for residents with complex medical and psychiatric needs. For one resident with multiple diagnoses including dysphagia, pulmonary fibrosis, heart disease, diabetes, Parkinson's disease, and malnutrition, the care plan lacked specific, measurable objectives and did not address individualized interventions for each diagnosis. The plan also failed to include details regarding the resident's NPO (nothing by mouth) status, specific oral care needs, and the speech therapy interventions being provided, despite the resident having a PEG tube and receiving tube feedings. Additionally, the ADL care plan did not specify that the resident was only to receive oral intake during speech therapy sessions, nor did it address oral care needs related to NPO status. In a separate case, the facility did not establish a care plan for another resident with psychiatric diagnoses, omitting necessary interventions to address those needs. These deficiencies were identified through medical record review and staff interviews, and were confirmed with facility leadership. The lack of comprehensive, resident-centered care plans resulted in the failure to address the unique clinical and psychiatric needs of the residents as required.
Failure to Consistently Change and Clean Incontinent Resident
Penalty
Summary
A deficiency was identified when a resident who is incontinent of bowel and bladder was not consistently changed and cleaned by nursing staff, as documented in the GNA Kardex. The records showed multiple instances across several days and shifts in June, July, and August where the resident was not changed, with specific dates listed for day, evening, and night shifts. During an interview, the DON and Administrator acknowledged that agency GNAs were unaware of where to document completed care. Additionally, during a facility tour, an area was noted to have a urine odor, and a resident complained about not being changed and experiencing long wait times for assistance. The Administrator did not respond to the complaint during the tour.
Failure to Provide Scheduled Showers for Resident Requiring Maximal Assistance
Penalty
Summary
Facility staff failed to ensure that a resident's personal hygiene needs were met by not offering or providing scheduled showers. Medical record review and staff interviews revealed that the resident, who required maximal assistance for bathing and had adequate cognitive ability, was scheduled to receive showers every Wednesday and Saturday. Documentation showed that from early December through late January, the resident only received two showers and did not receive any showers during the entire month of December. The Director of Nursing was unable to locate shower documentation sheets when questioned about the concern.
Failure to Monitor and Intervene for Resident's Decreased Intake Resulting in Hospitalization for Dehydration
Penalty
Summary
Facility staff failed to adequately monitor and respond to a resident's hydration and nutrition status, resulting in a significant change in the resident's condition. The resident, who was dependent on staff for feeding, experienced a marked decrease in oral intake over several days, with documentation showing missed meals and reduced intake from 3/1/25 to 3/5/25. Despite these changes, there was no evidence that the resident was assessed by the dietitian during this period, nor was there an updated nutritional assessment since 9/9/24. The resident's condition deteriorated to the point where they became nonverbal and unresponsive, requiring supplemental oxygen and an attempted IV, which could not be established by facility staff. The resident was subsequently transferred to a local hospital, where they were diagnosed and treated for dehydration. Hospital records confirmed that facility staff reported decreased oral intake prior to the transfer. Interviews with the facility dietitian revealed that reduced intake should have triggered an alert and a reassessment, but this did not occur. The Director of Nursing was informed of the failure to monitor the resident's intake and implement interventions to prevent dehydration.
Incomplete Medical Record Documentation for PT Evaluation
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for a resident. A review of the resident's electronic medical record showed a physician order for physical therapy (PT) to evaluate wheelchair and positioning, but there was no documentation available to confirm whether the evaluation occurred. During interviews, the Director of PT was unable to confirm or deny if the evaluations took place due to the absence of information in the electronic medical record. The Director of Nursing also confirmed that the medical record was not maintained in its most complete form for the resident. This deficiency was identified through medical record review and staff interviews, which revealed that required documentation related to a physician-ordered PT evaluation was missing from the resident's record.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment for a resident residing in a secure unit, which led to the resident eloping and being at increased risk for serious harm. The resident, who had a history of vascular dementia and impaired mobility, was identified as an elopement risk with exit-seeking behaviors. Despite having care plans in place to address these risks, the resident was able to leave the facility unsupervised. The incident occurred when the resident attended an outdoor activity on the patio attached to the locked unit. During the activity, the staff member responsible for supervision was assisting another resident, allowing the resident to open the gate and leave the enclosed area. The gate's locking mechanism had been disarmed due to a fire drill conducted the previous day, which was not properly secured afterward. The resident was found at a nearby hospital and returned to the facility without injuries. Interviews with staff revealed that the protocol for outdoor activities was not followed, as the gate was not checked to ensure it was locked, and there was insufficient supervision. The facility's investigation confirmed these lapses in protocol, contributing to the resident's elopement.
Removal Plan
- An in-service was completed with the maintenance staff that included the education training to check all exits after fire drills.
- An in-service was completed for staff on the protocol for resident safety during outside activities on the locked unit.
- Directions to split up residents into two different groups with two staff members.
- Activity and nursing staff to check the gate prior to outside activities to ensure that it's locked during activities.
- Collaboration with nursing staff with a roll call at the beginning of an activity and the end of an activity to make sure all the residents are accounted for.
- Activity staff and nursing staff have been educated on the steps to protect our patients from leaving the facility unaccompanied during outside therapeutic activities.
Failure to Maintain Clean Carpets
Penalty
Summary
The facility failed to maintain clean carpets, which was evident in several carpeted areas. On multiple occasions, surveyors observed sticky carpets in specific rooms, with shoes sticking to the floor. The Maintenance Director explained that the stickiness resulted from staff using an incorrect cleaning solution ratio. A review of the facility's work orders revealed numerous requests for carpet cleaning by staff. Additionally, complaints were received about dirty and sticky carpets in certain rooms dating back to 2023. The Nursing Home Administrator acknowledged the carpet issues and mentioned plans for replacement during upcoming renovations.
Failure to Timely Report Abuse Investigation Results
Penalty
Summary
The facility failed to report the results of an alleged abuse investigation within the required five working days to the Office of Health Care Quality. This deficiency was identified during a review of a facility-reported incident involving four residents. For Resident #375, an alleged abuse incident occurred on November 28, 2023, and the facility initiated an investigation and submitted a self-report on November 29, 2023. However, the final investigation report was not submitted until December 12, 2023, which exceeded the five-working-day requirement. The Director of Nursing confirmed the late submission during an interview with the surveyor. Additionally, on May 21, 2024, three residents alleged verbal and physical abuse by a geriatric nursing assistant. The facility submitted the initial report to the Office of Health Care Quality within 24 hours, as required. However, the final report was not submitted until May 31, 2024, again failing to meet the five-working-day deadline. The Director of Nursing and Unit Manager acknowledged the delay during an interview with the surveyor, confirming awareness of the late submission.
Failure to Inform Resident of New Medication
Penalty
Summary
The facility failed to inform a resident in advance of changes to their treatment plan, specifically regarding the initiation of a new medication. The deficiency was identified during a review of the medical records and interviews conducted as part of the complaint portion of the annual survey. The resident in question, admitted in 2021, has a medical history that includes congestive heart failure, hypertension, paroxysmal atrial fibrillation, and altered mental status. Despite being alert and oriented with some confusion, the resident remains their own healthcare decision-maker. On March 7, 2024, an order was written for a new medication, Semaglutide, to be administered weekly for diabetes control. However, there was no documentation in the medical record indicating that the resident was informed about the new medication or its potential side effects. Even after a visit from the medical team on March 15, 2024, there was no mention of the new medication or updates to the resident's plan of care.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving two residents. One resident was observed hitting another resident in the face, leading to the aggressor being sent to the hospital for emergency evaluation. In another incident, the same aggressor kicked a different resident in the face, although no injuries were noted, and the residents were immediately separated. The Director of Nursing acknowledged that the aggressor had adjustment problems managing behavior upon arrival at the facility and had involuntary movements due to their condition. Despite obtaining an Emergency Petition and transferring the aggressor for psychiatric care, the facility was unable to place the aggressor in another facility until behavior management was achieved, resulting in a failure to protect residents from abuse.
Failure to Suspend Staff During Abuse Investigation
Penalty
Summary
The facility failed to suspend a staff member during an ongoing abuse investigation, which was a deficiency identified by surveyors. The incident involved a resident whose responsible party reported an allegation of abuse, claiming the resident was beaten by staff. The facility conducted an investigation but was unable to substantiate the allegation. Despite this, the Geriatric Nursing Assistant (GNA) implicated in the allegation was not suspended; instead, they were reassigned and did not work with the resident in question. The Director of Nursing acknowledged that the GNA should have been suspended until the investigation was complete.
Incomplete Documentation Delays Home Health Services for Discharged Resident
Penalty
Summary
The facility failed to ensure complete and appropriate documentation in the medical record to meet the discharge needs of a resident. The deficiency involved a resident who was planning to return home with their daughter and required home health services, including physical therapy, occupational therapy, a home nurse, social work, and a home health aide. The interdisciplinary team discharge form indicated these services, and the resident signed the form. However, the home health agency later contacted the facility, stating that the physician notes did not reflect the need for home health care, delaying the start of services. The social worker set up home health services before the resident's discharge, but the home health agency requested clearer documentation to support the need for home care. Despite the social worker's efforts to obtain the necessary documentation from providers, there was a delay in response, leading to a gap in services for the resident. The nursing home administrator was involved in the communication with the home health agency, but the updated documentation was not provided until eight days after the resident's discharge, resulting in a delay in the initiation of home health services.
Supervision and Treatment Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to maintain supervision of a resident, leading to a fall incident. Resident #224, who had a history of dementia, impaired balance, and limited mobility, was left unsupervised in the shower room, resulting in an unwitnessed fall. The resident's care plan required assistance by one staff member during bathing or showering, and the facility's policy explicitly stated that residents should not be left unattended during baths. The fall occurred due to a broken shower chair, which had not been reported as broken prior to the incident. The Director of Nursing (DON) acknowledged the oversight in supervision and the failure to investigate the incident as a lack of supervision. Additionally, the facility staff failed to provide treatments according to a resident's plan of care. Resident #382, who had a history of congestive heart failure, hypertension, atrial fibrillation, diabetes, and an open wound on the left foot, had multiple wound care treatments ordered. However, the Treatment Administration Record (TAR) showed several instances where wound treatments were not documented as completed, and the DON could not explain the missing documentation. Although refusals were documented, the lack of documentation for completed treatments suggested that the dressing changes were not performed as ordered.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to uphold the residents' right to privacy and dignity during medication administration. This deficiency was observed when a Registered Nurse (RN) did not close the patient door or draw the room divider curtain while assessing residents, providing treatments, and administering medications. This lack of privacy was evident for three residents during the medication administration process. The RN acknowledged the oversight during an interview, stating that he usually closes the door during such procedures and was aware of the facility's policy on maintaining residents' privacy and dignity.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the local Ombudsman of a facility-initiated resident discharge or transfer, as required. This deficiency was identified during an annual survey when reviewing the case of a resident who had physician orders to be transferred to the emergency room for evaluation and treatment. The resident was discharged to the hospital and later returned to the facility. However, the discharge was not included in the report provided to the Ombudsman for the specified period. During an interview, the Director of Nursing confirmed that the facility was not sending the Ombudsman copies of notices of transfer or discharge provided to residents or their representatives.
Inaccurate MDS Coding for Resident Behavior
Penalty
Summary
The facility staff failed to accurately code a resident's status on the Minimum Data Set (MDS) assessment, which is a federally mandated tool used to gather information on each resident's strengths and needs. This inaccuracy was identified for one resident during the annual survey. Specifically, the MDS for this resident incorrectly indicated the absence of behavioral symptoms in the 7-day look-back period, despite documentation in the resident's record showing the presence of such behaviors. The MDS Coordinator acknowledged the error upon review and indicated that the coding should have been different.
Failure to Maintain Personal Hygiene for Dependent Resident
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for a dependent resident. On October 3, 2024, a surveyor observed a resident sitting at the edge of their bed wearing only an incontinence brief. The resident's medical record indicated they were dependent on assistance for bathing. A review of the shower records from September 8 to October 7, 2024, showed the resident received only four showers and one complete bed bath in 24 days, despite the facility's policy of providing showers twice per week. The Nursing Home Administrator confirmed the discrepancy in the shower schedule during an interview.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post updated nurse staffing information daily, as required. During a survey, it was observed that on two separate occasions, the staffing information displayed in the front lobby was outdated. On September 30th, the posted information was from September 27th, and on October 7th, it was from October 4th. The surveyor interviewed the Staffing Coordinator, who stated that she was responsible for posting the staffing information but did not work on weekends. She indicated that the nursing supervisor was supposed to update the information during weekends. The Nursing Home Administrator was informed of these findings, which highlighted a lapse in maintaining current staffing information over the weekends.
Failure to Complete Controlled Medication Counts
Penalty
Summary
The facility failed to ensure that an account of all controlled drugs was completed, as evidenced by the review of the Controlled Medication Shift Change Logs. During an observation of the medication cart, surveyors and an LPN identified that 6 out of 14 logs showed that a count of the controlled medications was not completed for 31 shifts. The facility's policy requires the incoming and outgoing licensed nurses to complete a count of all controlled medications locked in the medication cart. This deficiency was confirmed during interviews with the LPN and the Director of Nursing, who acknowledged the failure to adhere to the facility's policy.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to maintain a secure system for medication storage, as observed during a survey of the 2nd floor nursing unit. Three out of ten medication carts were found unlocked and unattended, containing various medications including insulin pens, which were improperly labeled or not labeled at all. The surveyor noted that the medication cart should be locked when not attended by authorized staff, a standard acknowledged by the Charge Nurse and the Director of Nursing during interviews. Additionally, the surveyor observed two medication storage rooms where medications were improperly stored and not disposed of correctly. On the third floor, a bag of individual medications was found in a drawer, which included various tablets and capsules that should have been disposed of in a red biohazard bag. Similarly, on the second floor, expired Heparin Flush pre-filled syringes were found mixed with unexpired ones, indicating a failure in proper medication management and disposal. These observations highlight the facility's deficiencies in securing medication carts and ensuring proper storage and disposal of medications. The staff interviews confirmed that the facility's expectations were not met, as medication carts were left unlocked and medications were not disposed of according to protocol.
Failure to Ensure Accurate Entry of Resident Information for Lab Specimens
Penalty
Summary
The facility failed to ensure accurate entry of resident information for laboratory specimens, resulting in the rejection and cancellation of samples for a resident. On September 3, 2024, a resident was ordered to have blood samples for a Comprehensive Metabolic Panel (CMP), Lipid Panel, Complete Blood Count (CBC) with differential, and a stool sample for Clostridioides difficile (C-diff). However, the outside laboratory company rejected these samples due to incorrect Date of Birth (DOB) information on the specimen tubes and cup, which was not corrected despite confirmation with the nurse. Further review revealed that on September 23, 2024, another blood sample for a CBC with differential was also rejected for the same reason. The Director of Nursing (DON) confirmed that the facility used an outside company for laboratory results and that nurses were responsible for entering orders into a web-based system, including the resident's DOB. The DON acknowledged that both samples, one obtained by the outside lab and the other by the facility's nurse, were discarded due to the same error, indicating a systemic issue in the process of labeling and entering resident information for laboratory specimens.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a survey. In the walk-in freezer, a frozen pork loin was found partially unwrapped with freezer burn and undated, along with a partial package of Polish Pork sausage in an opened plastic bag, also undated. The walk-in refrigerator contained nine packages of bologna past their expiration date and lacked an internal thermometer. In the dry storage room, three boxes of bananas were wrapped in plastic with condensation inside the bags, and nine boxes of Baker's Source Cake Mix were undated. Additionally, during a tour of the third-floor dining room, food stored in the Nursing Nutrition Refrigerator was found unlabeled. The Certified Dietary Manager acknowledged these issues, noting that facility policy requires securely wrapping and labeling food with open and expiration dates once opened.
Failure to Sanitize Medical Equipment Between Residents
Penalty
Summary
The facility failed to ensure proper sanitization of medical equipment between residents, as observed during a medication administration session. Registered Nurse (RN) #20 was seen using a blood pressure cuff and monitor on multiple residents without sanitizing the equipment between uses. Specifically, the RN did not sanitize the blood pressure cuff and monitor after using it on Resident #111, and continued this practice with Residents #424, #114, and #426. During an interview, RN #20 acknowledged the failure to sanitize the equipment and confirmed that the facility's protocol required sanitization of shared medical equipment after each use and between residents.
Failure to Notify Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to properly identify and notify the responsible party (RP) of changes in the residents' medical conditions and treatments. This deficiency was identified during the facility's annual and complaint survey for three residents. For one resident, despite a decisional capacity evaluation indicating the resident was incapable of making healthcare decisions, there was no documentation that the RP was notified of an increase in medication dosage. The resident had a history of congestive heart failure, hypertension, and other conditions, and a health care agent was in place to make decisions on their behalf. In another case, a resident's daughter, who was the RP, reported that medication changes were made without her being informed. The facility's records did not show any notification to the RP regarding changes to the resident's Aricept medication. Similarly, for a third resident, the RP was not notified about the initiation of Remeron. The Assistant Director of Nursing acknowledged the lack of notification and emphasized the expectation that medication changes should be discussed with the RP, highlighting a systemic issue in communication within the facility.
Delayed Call Bell Responses Lead to Care Deficiencies
Penalty
Summary
The facility failed to respond to call bells in a timely manner, affecting the care of several residents. Resident #81 reported waiting over an hour for assistance, while Resident #106 experienced a delay of hours for incontinent care. The call history reports confirmed multiple instances where the call bell response times exceeded the facility's expectation of 10 minutes, with wait times ranging from 41 minutes to 2 hours. The facility's procedure mandates timely responses to residents' requests, but the review revealed that staff did not have their pagers during some of these incidents, contributing to the delays. Additionally, Resident #382 experienced a significant delay in response to a call light, which was activated during the evening into the morning shift and was not canceled until over an hour later. This delay coincided with a medical emergency that required the resident to be sent to the hospital. The Nursing Home Administrator acknowledged that the response time was unacceptable, indicating a failure to meet the facility's standards for call bell response times.
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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