Sterling Care Bel Air
Inspection history, citations, penalties and survey trends for this long-term care facility in Bel Air, Maryland.
- Location
- 410 East Mcphail Road, Bel Air, Maryland 21014
- CMS Provider Number
- 215312
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Sterling Care Bel Air during CMS and state inspections, most recent first.
Respiratory care was not provided as required for multiple residents receiving O2 therapy. Surveyors observed unlabeled O2 tubing, a humidifier bottle on the floor, tubing left on a nightstand without a protective bag, and missing Oxygen In Use signs outside several resident rooms. An LPN confirmed tubing and masks were expected to be labeled and stored in a clean plastic bag when not in use, and the DON acknowledged the findings.
The facility failed to verify competency for newly hired GNAs before they provided resident care. Review of four GNA files found no skill verification or evaluation records, and the Educator stated she completed skill checklists for nurses but not aides. The NHA acknowledged that new hires were given checklists that were not returned and that there was no evidence the GNAs had completed competencies.
Failure to Document Capacity and Advance Directive Status: Staff did not properly document the rationale for incapacity on physician certification forms for multiple residents with severe cognitive impairment, including residents with BIMS scores indicating severe impairment. In addition, for one resident, the record did not show an Advance Directive on file or that the resident was asked about one or offered forms to complete one.
Failure to maintain resident privacy occurred when a resident was observed with the mid to lower body visible to visitors and staff because the blanket was pulled down and the privacy curtain was positioned all the way to the wall. The resident had moderately impaired cognition per BIMS and required partial/moderate assistance with lower body dressing, with the care plan identifying ADL self-care deficits and staff support needs for dressing, toilet use, and personal hygiene.
Incomplete Oxygen Therapy Care Plans: The facility failed to develop and implement comprehensive care plans for oxygen therapy for three residents who had active O2 orders and were observed using O2 via NC. Record review showed no evidence that care plans had been initiated or implemented for their oxygen therapy, and staff stated the plans were typically started on admission and completed the next day. The facility later provided oxygen care plans that had only been initiated after surveyor intervention.
A resident who required partial/moderate assistance with personal hygiene was observed with fingernails extending about half an inch beyond the fingertips, and the resident said staff had repeatedly been asked to trim them without success. A later observation confirmed the long fingernails remained, while staff stated that nail care was expected as part of regular ADL assistance.
The facility failed to follow a physician’s order for turning and repositioning a dependent resident, as staff observations showed the resident remained in the same position for hours despite a care plan and order for repositioning every 2 hours. The facility also failed to give pain medication on time for another resident; the resident reported the doses were often late, and the DON confirmed multiple late administrations of scheduled acetaminophen.
Incomplete medication refrigerator temperature logs were identified during a survey observation of the med storage room. Two refrigerators, including one for prescribed antibiotics and one for Pyxis emergency meds, had missing staff initials and only one documented temperature per day instead of the required AM and PM checks. An LPN/Night Shift Supervisor validated that the logs were not properly completed or maintained.
Room ID postings were inaccurate for two residents, and staff said they relied on the wall nameplates and other sources to identify residents. The facility also had inaccurate oral assessment documentation for one resident whose record showed no dentures and natural teeth despite the resident reporting dentures and denture pain, and another resident's care plan contained another resident's name and CPAP goal.
Infection control practices were not followed for a resident’s oxygen equipment, another resident’s urinary catheter drainage bag, and resident food stored in the nourishment room. Surveyors observed oxygen tubing and a humidifier bottle stored improperly, a catheter drainage bag lying on the floor, and a bag of resident food in the refrigerator without a documented date. Staff confirmed the expected storage and handling practices during the survey.
A resident with a right BKA requiring wound care was discharged home after the facility was notified that home health services could not be provided. Despite this, discharge instructions indicated that home health wound care was arranged. Staff interviews confirmed that the discharge plan was not updated to reflect the lack of wound care arrangements, and the resident was sent home with a wound vac and instructions to contact home health if needed.
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 facility failed to complete a criminal background check for an agency GNA, resulting in a GNA with prior assault and sexual assault convictions providing care to a resident dependent on staff for toileting after a stroke. The resident alleged sexual abuse by the GNA, leading to psychosocial harm and subsequent criminal charges against the GNA.
Surveyors observed that food and drink served to residents were not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency related to meal quality and safety.
Staff failed to maintain wheelchairs in safe and comfortable condition, as evidenced by multiple residents using wheelchairs with missing or damaged armrests, cracked or torn vinyl, and exposed foam padding. Maintenance staff relied on both electronic and verbal reporting for repairs, but deficiencies persisted, affecting resident safety and comfort.
Staff failed to properly perform and document neuro checks after falls for two residents, did not obtain current vital signs during a change in condition for another, and did not implement or accurately document required heel elevation for a resident on hospice. Additionally, a resident with low blood pressure did not have the value documented, no follow-up was performed, and the NP was not notified, leading to a significant decline in condition.
Staff inaccurately documented assessments, medication, and treatment administration for two residents who were not present in the facility, and falsely recorded that a hospice resident's heels were elevated as ordered when observations showed otherwise. The DON confirmed these inaccuracies after direct observation.
Facility staff did not promptly notify a provider when a resident experienced low blood pressure and had their antihypertensive medication withheld. The provider, who was present in the building, was only informed later when the resident became unarousable. The DON confirmed that the provider should have been notified earlier about the change in condition and the held medication.
Licensed nursing staff documented assessments, medication administration, and treatments for two residents after they had been transferred out of the facility and were no longer present. The DON confirmed that these records were inaccurate and did not reflect actual care provided, violating professional standards for nursing documentation.
A resident with a history of mood disorder, depression, and anxiety was given hydralazine, a medication for hypertension, instead of the intended hydroxyzine for anxiety, due to a transcription or communication error. The resident received 34 doses of the incorrect medication over an 11-day period before the error was identified and confirmed by both the psychiatrist and the DON.
Staff failed to keep medication and treatment carts locked when unattended, leaving prescription drugs and supplies accessible. A resident was found standing at an unattended medication cart containing insulin pens and syringes, with several opened insulin pens and vials not dated as required. Opened medications, including insulin and sterile water, were not labeled with opening dates, and some medications requiring refrigeration were not properly stored. Facility policy requires locked storage and proper refrigeration, but these procedures were not followed.
The facility failed to maintain a sanitary garbage dumpster area, with garbage strewn around and a partially open dumpster observed over three days. Interviews revealed no set cleaning schedule, and a hole in the dumpster allowed animals to access waste. Efforts to replace the dumpster were mentioned.
The facility failed to timely assess and document the nutritional needs of several residents, leading to significant weight loss and unclear administration of prescribed feedings. Residents experienced delayed nutritional assessments, incomplete documentation, and lack of intervention for weight loss. Interviews confirmed these deficiencies, highlighting a pattern of inadequate nutritional management.
The facility failed to provide snacks to residents who desired them, as observed during a survey. Eight residents reported not being offered snacks during the day or at night, contrary to the facility's policy. Staff interviews revealed that snacks were only provided at bedtime, and the Dietary Manager was unaware of the lack of daytime snacks. The Administrator was not aware of the issue and stated that snacks should be available during activities and before bedtime.
The facility failed to ensure staff wore appropriate PPE for two residents under enhanced barrier precautions (EBP). One resident required trach care, but the LPN did not wear a gown, indicating a lack of awareness about EBP requirements. Another resident with a draining wound did not receive proper PPE use during a dressing change. Additionally, infection control concerns were observed in shared bathrooms, including unlabeled urinals and improper storage of hygiene items.
The facility failed to maintain a clean and comfortable environment, as observed during a survey. In two nursing units, shared bathrooms had broken fixtures, and several residents' wheelchairs had missing or damaged armrests. The Maintenance Director, responsible for regular audits, was informed of these issues.
The facility's kitchen was found to be unsanitary, with accumulated food residue on surfaces, unlabeled food items, and unclean dishes stored as clean. These deficiencies, observed during a kitchen tour, posed a potential risk for foodborne illness for residents consuming food prepared in the kitchen.
The facility failed to execute an admission agreement with a resident, as required, at the time of admission. The resident's medical records lacked a signed admissions agreement, and interviews with staff confirmed the absence of this document. The resident was admitted while alert and oriented times 1, but the necessary documentation was not completed.
A resident's discharge summary was incomplete, lacking essential details such as a recapitulation of the stay, a final status summary, medication reconciliation, and a post-discharge care plan. This was confirmed by the DON during a survey.
The facility failed to perform neuro checks at correct intervals for two residents after falls, using outdated vital signs, and inaccurately ordered antibiotic eye drops for another resident, leading to a delay in treatment. These deficiencies were confirmed by the DON.
A facility failed to complete STAT labs for a resident in a timely manner. STAT labs, including a CBC and BMP, were ordered due to the resident's decreased blood pressure and elevated pulse. However, the labs were not drawn by the end of the day. The next morning, a telehealth physician noted the resident's shortness of breath and the incomplete labs, leading to a transfer to the Emergency Department. The ADON confirmed the labs were not done as expected.
The facility failed to maintain accurate medical records for two residents. One resident's MAR lacked documentation for Tylenol administration, while another resident's MAR/TAR had several blanks for enteral feedings, with no documentation of a trial to hold feedings. The DON and Corporate Nurse confirmed these deficiencies.
The facility failed to provide scheduled showers for two residents dependent on staff assistance during a COVID outbreak. One resident, with Cerebral Palsy and osteoarthritis, only received bed baths in December 2022, with no documentation of shower refusals. Another resident, with dementia and heart disease, did not receive scheduled showers in November 2023 after testing positive for COVID. The DON and ADON stated showers were given at the end of the day for COVID-positive residents, but the GNA was unaware of this policy.
A facility failed to monitor a resident's blood pressure and heart rate before administering Lisinopril, as required by the physician's orders. The Medication Administration Record did not document the necessary vital signs at the time of the 8:00 AM dose, and the Treatment Administration Record lacked specific times for when vital signs were taken. The Director of Nursing and Assistant Director of Nursing confirmed the oversight, and the Corporate Nurse was informed.
Respiratory Care Equipment and Oxygen Signage Not Properly Managed
Penalty
Summary
The facility failed to provide necessary respiratory care services for 5 of 6 residents reviewed for respiratory care. During the initial tour, surveyors observed unlabeled O2 tubing for Resident #102, a humidifier bottle on the floor and O2 tubing left on top of the nightstand without a protective bag for Resident #33, and no Oxygen In Use sign posted outside Resident #33's room. Surveyors also observed an unlabeled O2 tubing and humidifier bottle, with no Oxygen In Use sign posted outside Resident #22's room, as well as an unlabeled O2 tubing for Resident #8. In addition, surveyors observed no Oxygen In Use sign posted outside Resident #136's room. During interview, Staff #16 confirmed that when caring for residents on O2 therapy, nurses were expected to label the O2 tubing and mask based on facility policy and store them inside a clean plastic bag when not in use. The DON was notified of the concern and acknowledged the findings. Review of the facility's Oxygen Administration policy confirmed that oxygen tubing and masks/cannulas were to be changed weekly and as needed if soiled or contaminated, oxygen warning signs were to be placed on the room door where oxygen was in use, and cleaning and care of equipment were to follow facility policy.
Missing Competency Verification for Newly Hired GNAs
Penalty
Summary
The facility failed to ensure that newly hired Geriatric Nursing Assistants demonstrated competency in essential skills and techniques before providing resident care. During review of four randomly selected newly hired GNA employee files, the surveyor found that Staff #23, #24, #25, and #26 had been hired between March 2025 and January 2026, but none of their records contained competency documentation to verify that their skills had been assessed prior to working with residents. The Educator stated that the facility provided education to newly hired nursing department staff, but she did nurses' skill checklists and not aides' skill checklists. The Nursing Home Administrator acknowledged that the facility gave new hires a checklist that they did not return and confirmed there was no supportive evidence showing that the newly hired GNAs had completed competencies.
Failure to Document Decision-Making Capacity and Advance Directive Status
Penalty
Summary
Facility staff failed to ensure residents were properly evaluated for decision-making capacity and failed to document the rationale for incapacity on physician certification forms. For Resident #147, the medical record showed a BIMS score of 6, indicating severe cognitive impairment, and two physicians completed certifications stating the resident was unable to make decisions; however, neither physician documented a diagnosis or specific reason for the incapacity. For Resident #4, the record showed a MOLST completed as Full Code per the surrogate, and while one physician certification listed dementia as the reason for incapacity, the second required certification did not include any diagnosis or rationale. The same documentation issue was identified for Resident #30, whose record showed a BIMS score of 5 indicating severe cognitive impairment and two signed physician certifications stating the resident was unable to comprehend information and make decisions, but neither form included a diagnosis or specific rationale. For Resident #157, the clinical record did not contain a copy of an Advance Directive, and the social worker notes did not show that the resident was asked whether one existed or was offered forms to complete one. The Director of Social Services confirmed that the note was not completed and acknowledged that the resident should have been asked about an Advance Directive or offered one.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to provide adequate privacy to a resident by exposing the resident's body parts. During an observation on 3/09/2026 at 8:40 AM, Resident #136 was seen with an incontinent brief on and the blanket pulled down, while the privacy curtain was pulled all the way to the wall, leaving the resident's mid to lower body visible to visitors and staff. Staff #6 was immediately notified of the observation. Record review on 3/10/2026 showed the resident had a BIMS score of 11.0, indicating moderately impaired cognition. The resident's admission MDS documented lower body dressing as requiring partial/moderate assistance, and the care plan identified an ADL self-care performance deficit related to disease process, with the resident to receive appropriate staff support for dressing, toilet use, personal hygiene, bed mobility, transfers, and eating. On 3/11/2026, Staff #17 confirmed that staff were expected to provide privacy to residents, and the DON was notified of the concern.
Incomplete Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for oxygen therapy for 3 of 31 residents reviewed for care planning during the recertification survey. On 3/9/2026, Residents #22, #8, and #136 were observed using oxygen via nasal cannula. A review of active physician orders on 3/11/2026 confirmed that Resident #22 had an order for oxygen continuous at 2 liters via nasal cannula every shift, Resident #8 had an order for oxygen at 2 liters via nasal cannula continuous every shift for oxygen supplement, and Resident #136 had an order for oxygen continuous at 2 liters via nasal cannula every shift. A review of the medical records showed no evidence that care plans had been initiated or implemented to address oxygen therapy for Residents #22, #8, and #136. Staff #16 stated on 3/11/2026 that care plans were initiated by nurse supervisors on admission and then reviewed and completed by the Unit Managers the following day. On 3/12/2026, the Nursing Home Administrator provided oxygen care plans for the three residents, and those care plans had only been initiated on 3/12/26 after surveyor intervention. The facility's O2 Administration Policy revised on 1/20/26 stated that the resident's care plan shall identify the interventions for oxygen therapy based upon the resident's assessment and orders.
Failure to Provide Needed Nail Care During ADL Assistance
Penalty
Summary
The facility failed to provide necessary personal hygiene to a dependent resident who required assistance with ADLs. During the initial tour, Resident #136 was observed with fingernails extending approximately half an inch beyond the fingertips, and the resident stated that staff had been repeatedly asked to trim the nails without success. The resident was identified as needing partial/moderate assistance with personal hygiene on the admission MDS, and the care plan also indicated one-person assistance for personal hygiene. A follow-up observation confirmed that the resident still had long fingernails. Staff #17 and Staff #16 stated that staff and GNAs were expected to provide nail care as part of regular ADL assistance. The DON was later notified of the concern, and the resident's fingernails were trimmed.
Failure to Reposition a Dependent Resident and Late Pain Medication Administration
Penalty
Summary
The facility failed to follow a physician’s order for turning and repositioning a dependent resident. Resident #102 was observed on 3/09/2026 sleeping on the left side and slanted with the head pushed against the left side rail, and the resident remained in the same position during follow-up observations later that morning. The resident’s care plan identified the resident as totally dependent on 2 staff for repositioning and turning in bed as necessary, and the admission MDS indicated partial/moderate assistance for rolling left and right. The medical record also showed an order for turning and repositioning every 2 hours and as needed as tolerated every shift, although the TAR was signed by nursing staff indicating the task was performed. The facility also failed to administer pain medication on time for another resident. Resident #2 stated that pain medication was often late and said it often came every 10 hours. The resident’s physician ordered Acetaminophen 500 mg, 2 tablets by mouth twice daily for pain, scheduled for 8:00 AM and 8:00 PM. Review of the Medication Admin Audit Reports for February and March 2026 showed multiple late administrations, including doses given well after the scheduled times on numerous dates. The DON reviewed the ordered times and administration times and confirmed that the medication was administered late.
Incomplete Medication Refrigerator Temperature Logs
Penalty
Summary
The facility failed to consistently monitor and document the temperatures of its medication refrigerators. During an observation of the medication storage room with the Night Shift Supervisor, two refrigerators were identified: one used for residents' prescribed antibiotics and another for Pyxis emergency medication storage. Review of the temperature logs showed missing staff initials and incomplete twice-daily documentation in both logs. The Pyxis refrigerator log lacked staff initials from 3/03/26 through 3/06/26 and recorded only one temperature per day during that period, despite requiring AM and PM checks. The prescribed medication refrigerator log lacked staff initials from 3/01/26 through the AM of 3/09/26, and only a single checkmark was recorded for 3/07/26 through 3/09/26 instead of twice-daily monitoring. The Night Shift Supervisor validated that the temperature logs were not appropriately completed or maintained.
Room Identification Errors and Inaccurate Clinical Records
Penalty
Summary
Facility staff failed to ensure that residents' names were accurately displayed at room entrances. During an initial tour, the room posting for one room identified the door side as one resident and the window side as another resident, but the resident physically located on the door side verbally confirmed a different identity. An LPN confirmed that the D and W designations meant door side and window side and stated the nameplate should be changed. An RN later stated she relied on the wall-mounted nameplates to identify residents, and another staff member said she also relied on other staff, residents, and the nameplates when working with unfamiliar residents. The NHA and DON later validated the identification errors. The facility also failed to maintain accurate clinical records for oral assessment and resident care planning. For one resident, the surveyor observed dentures in the drawer and the resident reported that the bottom denture hurt at times, yet the medical record documented no dentures and recorded natural teeth present on oral assessments. The DON explained that nursing staff completed quarterly oral evaluations and residents with dental complaints were placed on a list for an outside dental company. In another case, a resident stated they had not been invited to care plan meetings, and the clinical record contained a care plan with another resident's name on it. The DON reviewed the incorrect care plan, stated it belonged to another resident with a CPAP goal, and said it had been written on the wrong resident's clinical record.
Infection Control Lapses With Oxygen Equipment, Catheter Care, and Undated Resident Food
Penalty
Summary
The facility failed to use appropriate infection control practices for oxygen administration equipment for Resident #33. During the initial tour, a humidifier bottle was observed on the floor and oxygen tubing was left on top of the nightstand without any protective bag in the resident’s room. During an interview, Staff #16 confirmed that per facility policy, oxygen tubing should be labeled and stored in a clean plastic bag when not in use. The facility also failed to maintain urinary catheter equipment for Resident #8 and failed to properly date resident food stored in the nourishment room for Resident #133. Resident #8’s catheter drainage bag was observed lying on the floor on two separate occasions, and Staff #11 stated that catheter bags must be kept off the floor and below the level of the bladder. In the nourishment room refrigerator, a plastic bag labeled with Resident #133’s name and room number lacked a documented date of entry or opening, and Staff #6 acknowledged that the resident’s food did not have a date on it.
Discharge Plan Not Updated After Home Health Services Declined
Penalty
Summary
The facility failed to update a resident's discharge plan to accurately reflect the status of home health services following a referral for wound care. The resident, who had a right below knee amputation (BKA) and required ongoing wound care, was discharged home with the expectation that home health wound care services would be provided. Although the facility initially contacted a home health agency to arrange for these services, they were notified prior to discharge that the agency would not be able to provide care. Despite this, the discharge summary and instructions given to the resident indicated that home health services were set up and that wound care would be provided on specific days. Interviews with facility staff, the resident, and the complainant confirmed that the resident was discharged with a wound vac machine and instructions to contact home health if issues arose, but no actual wound care arrangements were in place at the time of discharge. The Social Services Director acknowledged awareness that home health services had been declined prior to discharge, and the Medical Director confirmed that the discharge instructions should have been revised to reflect the lack of home health services. The resident was educated on the risks of being discharged without these services but still preferred to go home. The facility did not update the discharge plan to accurately reflect the absence of home health wound care arrangements.
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 notes 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. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Complete Background Check Allows GNA with Criminal History to Abuse Resident
Penalty
Summary
The facility failed to ensure a complete criminal background check was conducted for an agency GNA prior to allowing the individual to provide care to residents. Specifically, the GNA in question had a history of criminal convictions for assault and sexual assault, which was not identified due to an incomplete background check provided by the agency and overlooked by the facility's HR. As a result, the GNA was permitted to work in the facility and provide direct care to vulnerable residents, including one resident who was dependent on staff for toileting due to a history of cerebral infarction (stroke). This deficiency led to an incident in which the resident alleged that the GNA engaged in sexual abuse during care, including unwanted physical contact and sexual advances. The resident reported significant psychosocial harm, including distress, nightmares, and increased withdrawal following the incident. The facility's documentation and staff interviews confirmed that the background check was incomplete and that the incident was reported to authorities, with the GNA subsequently facing criminal charges and incarceration.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals served to residents, which were found to be unappealing and not at appropriate temperatures for safe and enjoyable consumption.
Failure to Maintain Safe and Comfortable Wheelchairs for Residents
Penalty
Summary
Facility staff failed to provide necessary maintenance services to resident wheelchairs, resulting in multiple deficiencies related to the safety and comfort of residents. During a complaint survey, observations revealed that 15 out of 37 residents had wheelchairs with missing or damaged armrests, cracked or torn vinyl, and exposed foam padding. In several cases, both armrests were missing, and one resident was noted to have several bruises on their arms. These deficiencies were observed during initial rounds and throughout the survey period. Interviews with the Director of Maintenance indicated that repair orders were typically submitted through an electronic system accessible to all staff, but staff often reported issues verbally instead. The Director of Maintenance stated that wheelchair maintenance, including armrests and brakes, was performed monthly and expected staff to notify him of any issues. Despite the availability of extra wheelchairs and the ability to swap them out, the observed deficiencies persisted, indicating a failure to maintain wheelchairs in a safe and comfortable condition for residents.
Failure to Provide and Document Required Care and Assessments
Penalty
Summary
Facility staff failed to provide appropriate care and documentation for multiple residents, resulting in deficiencies related to neurological assessments, skin care, and medication management. In two separate incidents, staff did not properly perform or document neuro checks after residents experienced falls. For one resident, only a single neuro check was documented after a fall, despite the expectation that checks be performed every 15 minutes for the first hour. Another resident also had incomplete neuro check documentation following a fall, with significant gaps between recorded assessments. Additionally, staff failed to obtain current vital signs during a change in condition for one resident, instead relying on outdated information. In another case, a resident on hospice care with orders to have their heels floated while in bed was repeatedly observed with their heels resting directly on the mattress, despite documentation indicating otherwise. Multiple observations confirmed that the intervention was not being implemented as ordered, and nursing staff had signed off on the treatment administration record as if the intervention had been performed. The Director of Nursing confirmed the discrepancy between documentation and actual care provided. A further deficiency involved the management of a resident's low blood pressure. When a blood pressure medication was held due to low readings, staff failed to document the actual blood pressure value, did not record a follow-up measurement, and did not notify the nurse practitioner or physician. The nurse practitioner, who was present in the building, was not informed of the situation until the resident's condition deteriorated significantly, resulting in transfer to the emergency room. The lack of timely communication and documentation was acknowledged by both the nurse practitioner and the Director of Nursing.
Inaccurate Medical Record Documentation and Failure to Follow Physician Orders
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for multiple residents, as evidenced by documentation of assessments and medication administration for residents who were not present in the facility. For one resident, staff documented a Change in Condition Assessment, neurological checks, pain assessment, and skilled nursing charting after the resident had been transferred to the emergency room and did not return. Additionally, medication administration was recorded for this resident on the day following their discharge from the facility. Another resident's records showed that staff documented the administration of multiple medications and treatments, including wound care and tube feeding, on a date after the resident had been transferred to the hospital and was no longer in the facility. The Director of Nursing confirmed that these entries were inaccurate and that the resident was not present at the time the care was documented. A third resident, who was on hospice care, had physician orders to have their heels floated while in bed. Despite this, repeated observations found the resident's heels resting directly on the mattress, with no elevation as ordered. Nursing staff had signed off in the Treatment Administration Record that the heels were elevated during these periods, even though direct observation by surveyors and the DON confirmed otherwise.
Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
Facility staff failed to timely notify a resident's physician or nurse practitioner of a significant change in condition. Specifically, a resident with multiple diagnoses, including generalized weakness, peripheral artery disease, COPD, slurred speech, history of falls, and hypertension, was not given their prescribed amlodipine due to low blood pressure, as documented in the medical record. Despite this change in condition and the withholding of medication, the nurse practitioner was not informed while present in the building that morning. The nurse practitioner stated that she was only notified at lunchtime when the resident became unarousable, and not at the time the low blood pressure was first identified and the medication was held. The Director of Nursing confirmed that the nurse practitioner should have been notified about the low blood pressure and the decision to withhold the medication. This lack of timely communication regarding the resident's change in condition constituted the deficiency identified during the complaint survey.
Inaccurate Documentation of Care for Absent Residents
Penalty
Summary
Licensed nursing staff failed to meet professional standards of practice by documenting assessments, medication administration, and treatments for residents who were not present in the facility. For one resident admitted for rehabilitation following hospitalization, staff documented a change in condition assessment, neurological checks, pain assessment, and skilled charting after the resident had been transferred to the emergency room and did not return. Additionally, medication administration was recorded for this resident after discharge, including specific medications and times, despite the resident's absence from the facility. The Director of Nursing confirmed these inaccuracies in documentation. Similarly, for another resident who had been transferred to the hospital and did not return, staff documented the administration of multiple medications and completion of various treatments, such as wound care and tube feeding, on a date after the resident had left the facility. The Director of Nursing also confirmed that these entries were inaccurate. These actions constitute violations of professional documentation standards, as records did not accurately reflect the residents' status or care provided.
Medication Error: Administration of Unnecessary Drug Due to Order Transcription Mistake
Penalty
Summary
A resident with a history of mood disorder, depression, and anxiety was admitted to the facility and later evaluated by a psychiatrist, who intended to prescribe hydroxyzine for anxiety. However, due to a transcription or communication error, hydralazine—a medication used for hypertension and heart failure—was ordered and subsequently administered to the resident for anxiety. The medication administration record confirmed that the resident received hydralazine 50 mg every 8 hours for anxiety over a period of approximately 11 days, totaling 34 doses. This error was confirmed through interviews with both the psychiatrist and the Director of Nursing, who acknowledged that the resident was given hydralazine instead of the intended hydroxyzine.
Unattended and Unlocked Medication Carts, Undated and Improperly Stored Medications
Penalty
Summary
Facility staff failed to keep treatment and medication carts locked when unattended, as observed on one of two nursing units during a complaint survey. An unlocked and unattended treatment cart was found in front of the nurse's station, containing prescription creams, ointments, dressing supplies, and a bottle of sterile water irrigation with no date indicating when it was opened, despite sterile water being usable for only 24 hours after opening. Additionally, an unlocked and unattended medication cart was found in the hallway, with a resident standing at the cart and no nursing staff present. The surveyor was able to access the cart, which contained insulin pens, syringes, and a cell phone. Multiple insulin vials and pens for several residents were found opened but not dated, contrary to manufacturer instructions that require insulin to be used within 28 days of opening. Some unopened insulin pens were stored in a plastic bag labeled for refrigeration until opened, but there was no indication that opened pens were being refrigerated as required. Facility policy requires all compartments containing drugs and biologicals to be locked when not in use and mandates refrigeration for medications that require it. These deficiencies were confirmed through observation, staff interviews, and review of facility policy.
Improper Waste Management in Dumpster Area
Penalty
Summary
The facility failed to maintain the garbage dumpster area in a sanitary manner, as observed over three consecutive days. Garbage was found strewn around the dumpster, extending up to 30 feet away, and included items such as single-use disposable gloves, plastic bags, cups, lids, straws, cardboard, and food containers. A garbage bag was stuck in the lower-level opening of the dumpster, partially opened, and a 55-gallon garbage can was uncovered with garbage bags protruding from the top. These observations were made on multiple days, indicating a persistent issue with waste management in the facility. Interviews with the Housekeeping/Laundry Director (HKSD) and the Maintenance Director (MD) revealed that there was no established schedule for cleaning the dumpster area, and it was checked periodically by staff. The HKSD acknowledged that there should not be any garbage on the ground or uncovered garbage cans, and noted that animals such as cats and raccoons had been seen pulling garbage from a hole in the dumpster. The MD confirmed that the dumpster had a hole, which contributed to the issue, and stated that efforts were underway to replace it to ensure it was completely sealed.
Inadequate Nutritional Assessment and Documentation
Penalty
Summary
The facility staff failed to assess and evaluate the nutritional needs of several residents in a timely manner, leading to significant weight loss and inadequate nutritional interventions. Resident #902 was admitted with a weight of 129 pounds, but a nutritional assessment was delayed until eight days after admission. Despite a documented weight loss of 15 pounds by 2/10/22, there was no further assessment or intervention by the dietitian, and the resident was discharged shortly after. Similarly, Resident #904 experienced a 14.3-pound weight loss without timely nutritional assessment or intervention, and the resident's nutritional assessment was incomplete. Resident #906's nutritional needs were not adequately addressed, as the facility staff delayed ordering a prescribed house shake for six days and failed to obtain a weekly weight as per the facility's guidelines. Resident #911 experienced a significant weight loss without any nutritional assessment or intervention during their stay. Additionally, Resident #901's medication administration records showed several instances where it was unclear if the resident received their prescribed bolus feedings, as there were numerous blanks in the documentation. Resident #910's records revealed a lack of documentation for water flushes and enteral feedings, making it impossible to confirm if the resident received the prescribed nutrition and hydration. Interviews with the Director of Nursing and other staff confirmed these deficiencies, highlighting a pattern of inadequate nutritional assessment and documentation across multiple residents, leading to potential health risks due to insufficient nutrition and hydration management.
Failure to Provide Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were available to residents who desired them, as observed during a survey. Eight residents expressed that they were not offered snacks during the day or at night, despite the facility's policy stating that snacks should be readily available in accordance with residents' needs, preferences, and requests. Interviews with residents revealed that they were not offered snacks during the day or at bedtime, and some residents had to rely on vending machines for snacks. Observations by surveyors over several days confirmed that snacks were not distributed to residents on any of the units during the day. Interviews with staff, including a Geriatric Nursing Assistant and a Dietary Aide, indicated that snacks were only provided at bedtime, and there were no daytime snacks sent to the units. The Dietary Manager, who was new to her position, acknowledged the lack of routine snack distribution during the day. The Registered Dietitian confirmed that the dietary department only provided bedtime snacks. During a resident meeting, several residents stated that they were not offered snacks during the day or before bedtime, and they noted that only residents with special reasons received snacks. The facility's Administrator was unaware of the issue and stated that residents should have snacks available during activities and before bedtime.
Inadequate PPE Use and Infection Control Practices
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) for two residents, R13 and R51, who were under enhanced barrier precautions (EBP) due to their medical conditions. R13, who was moderately cognitively impaired, required trach care, but the LPN providing care did not wear a gown, despite having access to PPE gowns. The LPN was unaware of the EBP requirements, indicating a lack of proper training or adherence to infection control policies. Interviews with staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that there was a misunderstanding or lack of awareness about the necessity of EBP during trach care. For R51, who had a diagnosis of heart failure, chronic obstructive pulmonary disease, and peripheral vascular disease, the facility also failed to follow EBP. R51 had a wound on the left lower extremity with moderate serous drainage and was receiving antibiotics. During a dressing change, the LPN did not wear a gown, only gloves, despite the wound's condition and the resident's ongoing antibiotic treatment. The staff believed that EBP was not necessary since the wound was not actively draining, showing a gap in understanding of the EBP policy. Additionally, during a facility tour, several infection control concerns were observed, including unlabeled urinals and improper storage of personal hygiene items in shared bathrooms. These observations indicate a broader issue with infection control practices within the facility. The DON acknowledged the lack of a policy for the storage of bedpans and urinals, further highlighting the facility's deficiencies in maintaining proper infection control standards.
Environmental Deficiencies in Resident Rooms and Equipment
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment, as observed during a recertification/complaint survey. In two of the three nursing units observed, several deficiencies were noted. In the shared bathrooms of rooms 116-118, toilet paper was improperly placed on the grab bar, and the toilet paper holder was broken off the wall. Additionally, in one room, the drywall was damaged, leaving a significant gap between the base and the wall. In the dining areas, multiple residents were observed in wheelchairs with missing or damaged armrests. Specifically, one resident's wheelchair lacked an armrest on the left side, while another's had a ripped vinyl covering with no padding. Another resident's wheelchair had a cracked vinyl armrest, and yet another had a torn vinyl armrest. The Maintenance Director, who was responsible for auditing wheelchairs weekly and rooms monthly, was informed of these issues during a tour with the surveyor.
Sanitation Deficiencies in Kitchen Lead to Potential Foodborne Illness Risk
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, which could potentially lead to the spread of foodborne illness among residents. During an initial tour of the kitchen, several issues were observed, including accumulated food and beverage residue on service carts, stainless-steel tables, and shelving. Additionally, a bulk storage container of white granules was not labeled, and the Dietary Manager (DM) confirmed it was salt. Unclean plastic cereal bowls were stored as clean, and a black/grey substance was noted on the wall above the dishwasher. The interior of the microwave was also covered with food spatters. On a subsequent observation, the container of salt remained unlabeled, and several plastic coffee cups stored as clean had food particles adhered to their interior surfaces. The DM acknowledged these issues, stating that the kitchen had been cleaned after the initial tour, but the labeling of the salt was overlooked. These deficiencies affected 105 out of 117 residents consuming food prepared in the kitchen, creating a potential risk for foodborne illness.
Failure to Execute Admission Agreement
Penalty
Summary
The facility failed to review and execute an admission agreement, which includes a notice of the resident's rights, with a resident and/or the resident's responsible party at the time of admission. This deficiency was identified during a recertification/complaint survey for one of the 33 complaint residents reviewed. Specifically, the medical records of Resident #906, who was admitted to the facility and was alert and oriented times 1, did not contain a signed copy of the admissions agreement. An interview with the Admissions Coordinator revealed that she was not employed at the time of the resident's stay and confirmed that the admissions contract could not be found. The Director of Nursing also confirmed the absence of an admissions contract for the resident.
Incomplete Discharge Summary for a Resident
Penalty
Summary
The facility staff failed to complete a discharge summary for a resident, identified as Resident #913, who was discharged from the facility. Upon review of the closed medical record, it was found that the discharge summary was missing critical components such as a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre-discharge medications with post-discharge medications, and a post-discharge plan of care. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the completed discharge summary in the resident's medical record.
Deficiencies in Neuro Checks and Medication Orders
Penalty
Summary
The facility failed to provide adequate care for three residents, as evidenced by improper execution of neuro checks and incorrect medication orders. For one resident, after a fall, the facility staff did not perform neuro checks at the correct intervals as per the facility's protocol. The neuro checks were conducted using outdated vital signs, and the intervals did not align with the required schedule. This was confirmed by the Director of Nursing (DON) during an interview. Another resident also experienced a similar issue where neuro checks were not performed at the correct intervals, and outdated vital signs were used, which was again confirmed by the DON. Additionally, the facility staff inaccurately ordered antibiotic eye drops for another resident, prescribing them for only one day instead of the recommended 7 to 10 days for conjunctivitis. This error led to a delay in administering the medication, as the eye drops were not given on the first two days and were only reordered and administered three days later. The DON confirmed the inaccuracy in the order and the subsequent delay in treatment.
Failure to Complete STAT Labs in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident's laboratory tests were completed in a timely manner. On February 24, 2024, STAT labs, including a CBC and BMP, were ordered for Resident #40 due to decreased blood pressure and elevated pulse. However, by 10:13 PM on the same day, the labs had not been drawn. The following morning, a telehealth physician noted that the resident had been experiencing shortness of breath since the previous day and was not doing well. The physician also documented that the STAT labs ordered the day before had not been completed, leading to the decision to transfer the resident to the Emergency Department. The Assistant Director of Nursing confirmed that the labs were not done as expected on February 24, 2024.
Incomplete Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents during a recertification/complaint survey. For one resident, a nursing note documented that Tylenol was administered for lower back pain, but the Medication Administration Record (MAR) for that date was blank, indicating a lack of documentation for the medication given. The Director of Nursing and Assistant Director of Nursing confirmed that the MAR should have been signed off by the nurse when the medication was administered. For another resident, the March 2022 Medication Administration Record/Treatment Administration Record (MAR/TAR) showed an order for enteral feeding with Jevity to be given four times per day. However, there were several blank spaces on the MAR/TAR, making it unclear whether the feedings were administered. The Corporate Nurse confirmed that a week's worth of early morning feedings were trialed to be held to encourage the resident to eat more, but this was not documented on the TAR. Additionally, there was no explanation for the other missing nurse's initials for the feedings.
Failure to Provide Scheduled Showers During COVID Outbreak
Penalty
Summary
The facility failed to provide necessary showers for residents who were dependent on staff assistance for bathing. This deficiency was identified during a recertification/complaint survey for two residents. One resident, admitted in April 2021 with diagnoses including Cerebral Palsy and osteoarthritis, was scheduled to receive showers twice a week but only received bed baths throughout December 2022. There was no documentation of shower refusals, and the Geriatric Nursing Assistant (GNA) responsible for the resident was unaware of any refusals, as it was not documented. Another resident, admitted in August 2021 with dementia, heart disease, and osteoarthritis, also did not receive scheduled showers during a COVID outbreak in November 2023. The resident, who tested positive for COVID, was supposed to receive showers twice a week but only received bed baths until late November. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated that showers were given to COVID-positive residents at the end of the day, but the GNA was not aware of this policy and did not document any refusals. The corporate nurse and DON were informed of the missed showers during the outbreak.
Failure to Monitor Vital Signs Before Administering Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring the blood pressure and heart rate before administering a blood pressure medication as per the physician's orders. This deficiency was identified during a recertification/complaint survey for one resident. The physician's order for Lisinopril 20 mg, prescribed for hypertension, included specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was below 60. However, the Medication Administration Record (MAR) for March 2022 did not document that these vital signs were monitored at the time of the 8:00 AM dose of Lisinopril. Further review of the Treatment Administration Record (TAR) showed that vital signs were taken each shift, but the times were not recorded, and they did not align with the administration time of the medication. During an interview, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the lack of documentation and acknowledged that the blood pressure and heart rate should have been recorded on the MAR where the Lisinopril was listed. The Corporate Nurse was also informed of these findings.
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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