White Oak Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hyattsville, Maryland.
- Location
- 6500 Riggs Road, Hyattsville, Maryland 20783
- CMS Provider Number
- 215024
- Inspections on file
- 20
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at White Oak Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, hemiplegia, dysphagia, and multiple other complex conditions repeatedly called out for help for 29 minutes without staff response. The care plan identified the resident as a fall risk and dependent for transfers, with interventions to keep items within reach and remind use of the call light, yet during the incident the call light was on the floor and unreachable. Staff interviews confirmed they heard the resident yelling but did not intervene, assuming others were addressing the situation, while the unit manager acknowledged awareness of the calls and that staff were occupied elsewhere. The DON later confirmed awareness of the event and that staff involvement in another situation contributed to the delay in responding.
A resident with a G-tube and multiple neurologic and gastrointestinal diagnoses was ordered NPO with enteral feeding only, with instructions to check gastric residuals before feeding and to follow Enhanced Barrier Precautions for high-contact care. During an observed tube-feeding procedure, an RN did not perform hand hygiene, did not check gastric residuals as ordered, failed to use required PPE, and repeatedly touched bed controls, linens, the over-bed table, the door, a water pitcher, and bathroom fixtures with the same pair of gloves before handling the feeding tube. The RN placed a flushing syringe on the resident’s linens and reused it, did not clean the bedside table before placing supplies, and did not change gloves or perform hand hygiene at any point, which facility leadership later confirmed did not meet expected infection control and tube-feeding practices.
A portion of a unit was locked following an elopement, resulting in multiple residents being unable to exit freely and requiring staff assistance to leave. Several cognitively intact residents confirmed they did not have the code to open the door, and there was no documentation supporting the need for these restrictions. One resident, distressed by the confinement, sustained fractures while attempting to exit the locked area.
Several residents with cognitive impairment and high risk for elopement or wandering were not properly supervised, resulting in unsupervised exits from the facility and repeated incidents of residents entering others' rooms. Additionally, residents who required supervision while smoking were observed smoking unsupervised and without required safety equipment, and care plans did not consistently address noncompliance or provide adequate interventions.
Four residents did not have Advance Directives or documentation that information about Advance Directives was offered in their medical records. A staff member confirmed that the process to provide and document this information had not been done consistently.
Surveyors identified multiple deficiencies in the facility's housekeeping and maintenance, including unsecured bathroom fixtures, unsealed toilets, foul-smelling substances, damaged walls, and unclean windows. A resident was found in a room with cobwebs and debris in the window, and another had duct tape on the chair railing near the bed. These conditions compromised the sanitary and homelike environment expected for residents.
Several residents did not have complete, individualized care plans addressing their specific needs, including dental care, hospice status, elopement risk, and smoking safety. For example, a resident requiring dental extractions had no care plan for dental issues, another on hospice care lacked an updated care plan, and residents at high risk for wandering or with smoking safety needs did not have appropriate interventions documented in their care plans.
Surveyors found that dry goods such as flour, rice, and sugar were stored past their labeled expiration dates, and an opened bag of frozen pepperoni in the kitchen freezer was not labeled with the date it was opened or its expiration date, contrary to facility policy and professional food safety standards.
A resident reported that the Business Office was holding mail for an extended period. Interviews confirmed that a backlog of undelivered mail had accumulated because the previous Business Office Manager worked remotely and was not present to distribute mail. The facility's policy requires prompt forwarding of mail to residents.
Two residents experienced loss of property and funds due to staff actions. In one case, a resident's controlled pain medication went missing after multiple LPNs failed to properly count and document controlled substances during shift changes. In another case, a resident loaned money to a GNA after an ATM withdrawal, but the GNA did not repay the loan and avoided further contact.
A resident was transferred to a hospital without receiving written notification of the facility's bed-hold policy, and staff confirmed that no such documentation was provided prior to the transfer.
A resident was observed uncovered in bed with an exposed brief and only a partially drawn privacy curtain, making them visible to others in the room. The GNA involved admitted the curtain should have been fully closed, and the resident stated that staff never close the curtain, demonstrating a lack of attention to privacy and dignity.
A resident with dementia and a history of elopement, who was assessed as high risk and had a wander guard in place, was not accurately coded for wandering behavior or the use of a wander guard in the MDS assessment. Despite documented interventions and observations, the MDS failed to reflect the resident's actual condition and care needs.
A resident was not offered the opportunity to participate in care planning meetings following multiple MDS assessments, as required. Record review and staff interviews confirmed that care plan meetings were not held after several quarterly and annual assessments, resulting in the resident and their representative not being included in the care planning process.
A resident admitted after a stroke did not have a cardiology follow-up appointment scheduled as ordered by the physician. Due to a breakdown in communication and process, the appointment was not scheduled within the required timeframe, resulting in a failure to meet professional standards of care.
A resident did not receive a prescribed dose of Lacosamide 150mg as ordered by the physician. Review of medication records and a controlled substance count revealed a discrepancy between the number of tablets in the blister pack and the count sheet, and staff confirmed the medication had not been administered during the shift.
A resident's controlled substance medication, Lacosamide 150mg, was not accurately reconciled when the number of tablets in the blister pack did not match the controlled substance count sheet. Staff signed off on the shift count without performing the required dual count with another nurse, and the medication was not administered as documented.
A resident who required multiple dental extractions and expressed difficulty eating was not provided with timely dental care, despite a Prosthodontist's evaluation and recommendation. Staff interviews revealed a lack of awareness and follow-up, with cost and insurance issues cited as reasons for the delay.
Multiple deficiencies were identified in the facility's medical record-keeping, including incorrect or incomplete cognitive assessments, inconsistent documentation of care such as bathing, and delayed or inaccurately recorded medication administration. These issues resulted in conflicting or missing information in residents' records, failing to meet professional standards for medical documentation.
A resident with a tracheostomy was repeatedly observed with their extension tubing and drainage bag stretched across the floor and connected to their trach collar. Staff and the infection preventionist confirmed that this was not in accordance with infection control protocols, but the issue continued despite being reported.
Surveyors observed that two resident bathrooms had maintenance issues, including a missing cove base and peeling paint on the floor. These deficiencies were confirmed during interviews with the NHA and ADON.
The facility did not report allegations of abuse and misappropriation of resident property within the required timeframes. In three reviewed incidents, including a resident's report of stolen money and two separate abuse allegations, notifications to the State Agency were delayed beyond regulatory requirements, and follow-up with the affected resident was not conducted.
Nurse staffing information was not posted in a location that was easily accessible to all residents and visitors on the Med Bridge unit. The staffing schedule was placed on the locked side of the unit, making it difficult for 17 residents on the unlocked side to view, and staff confirmed the information was not readily visible.
Failure to Respond Timely to Resident’s Repeated Calls for Help
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely staff response to a resident’s repeated verbal calls for assistance. The resident had multiple complex diagnoses, including hemiplegia following cerebral infarction, dementia with behavioral disturbance, dysphagia, cognitive communication deficit, dysarthria, psychosis, spinal stenosis, disc degeneration, adult failure to thrive, anxiety disorder, obstructive and reflux uropathy, and an artificial urinary opening. The care plan identified the resident as a fall risk related to weakness and noted severe cognitive impairment, dependence for bed-to-chair transfers, an indwelling catheter, and bowel incontinence. Interventions included placing common items within reach and reminding the resident to use the call light for assistance with ADLs. On the day of the incident, the surveyor observed the resident calling out loudly for help from their room. Over a 29-minute period, no staff responded to the resident’s repeated verbal calls for assistance. During this time, the surveyor inquired at the front desk about the location of the nurse or GNA for the unit, but no staff were visible in the area. The unit manager later stated that there were five GNAs and two nurses scheduled, but one GNA was working as the scheduler and another had left the floor, and that staff were in other residents’ rooms. The manager acknowledged awareness that the resident was yelling for help and commented that the resident usually yells like that. Interviews with staff confirmed that they heard the resident calling out but did not respond. One CNA, who was observed sitting at a desk, stated that they heard the resident screaming but assumed the unit manager or others were addressing it and acknowledged that the resident’s call light was on the floor and unreachable. This CNA stated that the typical response when a resident calls for help is to attend and determine what is needed, and admitted they could have gone back to the room more times to assist. The unit manager later acknowledged that staff, including themselves, should have checked on the resident when they were yelling for help. The DON also stated awareness of the incident and noted that the unit manager and other staff were involved in a situation at the time, contributing to the delay in addressing the resident’s needs.
Failure to Follow Infection Control and Tube-Feeding Orders During G-Tube Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed infection prevention and control practices and physician orders during gastrostomy tube care for one resident receiving enteral feeding. The resident had diagnoses including gastrostomy malfunction, dysphagia following cerebral infarction, esophagitis with bleeding, and hemiplegia and hemiparesis following cerebral infarction, and was ordered NPO with G-tube feeding only. Physician orders required checking gastric residuals prior to feeding and following specific parameters if residuals exceeded 120 mL, as well as adherence to Enhanced Barrier Precautions for high-contact care such as tube feeding. During an observed tube-feeding procedure, the assigned RN did not perform hand hygiene before donning gloves, did not check gastric residuals prior to feeding as ordered, and did not follow Enhanced Barrier Precautions, including required PPE. During the same observation, the RN touched bed controls, linens, the over-bed table, the resident’s door, water pitcher, restroom door handle, and faucet with the same pair of gloves, without changing gloves or performing hand hygiene, and then handled the feeding tube. The RN placed a syringe used for flushing directly on the resident’s linens and reused it, and did not clean the bedside table before placing supplies. The RN also closed the resident’s door with gloved hands and did not change gloves or perform hand hygiene at any point during the procedure. In subsequent interviews, the RN acknowledged not performing their usual steps of hand hygiene, checking residuals, cleaning the bedside table, or following the expected door-closing protocol, and facility leadership confirmed that the observed practices did not align with expected infection prevention and tube-feeding procedures.
Involuntary Seclusion and Resident Harm Due to Locked Unit
Penalty
Summary
Residents in the Med Bridge unit were subjected to involuntary seclusion when a portion of the unit was locked, restricting their ability to move freely. This action was initiated following an elopement incident, and as a result, 15 residents were confined behind a locked door without documented clinical justification for such restriction. Among these, three residents with intact or moderately impaired cognition confirmed they did not have the code to exit and required staff assistance to leave the unit. There was no evidence in their records indicating a need for placement in a secure, locked environment. The remaining residents were not interviewable and also lacked documentation supporting the necessity for such confinement. One resident experienced significant distress due to the locked environment, resulting in self-inflicted physical harm while attempting to exit the unit. This resident was observed banging on the locked doors and subsequently sustained acute fractures, requiring hospital treatment. Staff interviews confirmed that the locked unit was established as a temporary measure for wandering residents, but no individualized assessments or documentation supported the restriction for the affected residents.
Failure to Prevent Accidents Due to Inadequate Supervision and Hazard Controls
Penalty
Summary
Multiple deficiencies were identified related to the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents. Several residents with cognitive impairments and high risk for elopement or wandering were not properly supervised or monitored. In one instance, a resident with severe cognitive impairment and a high elopement risk was able to exit the facility unsupervised due to malfunctioning wander guard systems and inadequate staff response to door alarms. Staff failed to confirm the resident's presence after an alarm was triggered, resulting in the resident being found offsite by emergency services and returned to the facility. The facility also failed to properly assess, supervise, and monitor residents during smoking activities. Residents who were identified as dependent smokers, or who had cognitive impairments, were observed smoking unsupervised in facility courtyards. In several cases, residents did not use required safety equipment such as smoking aprons/blankets, and independent smokers were observed assisting dependent smokers in violation of facility policy. Care plans for these residents did not consistently address noncompliance with smoking policies or provide adequate interventions for their supervision needs. Additionally, residents with known wandering behaviors were not effectively monitored or provided with updated care plan interventions following repeated incidents of entering other residents' rooms and engaging in altercations. Despite documented incidents of wandering and aggressive behavior, care plans were not revised to include additional safety measures. Staff interviews confirmed that expectations for monitoring were not consistently met, and multiple incidents occurred where residents with severe cognitive impairment wandered into unsafe situations or other residents' rooms without timely staff intervention.
Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that four residents were offered information regarding Advance Directives, as required. During a record review, it was found that there was neither an Advance Directive nor documentation indicating that information about Advance Directives had been offered to these residents in their electronic medical records. When the surveyor inquired about the missing documentation, a staff member acknowledged that an audit had been started to identify residents needing Advance Directives and that outreach to residents and responsible parties had begun, but this process had not been performed consistently. The absence of both the Advance Directives and documentation of having offered the information was confirmed for the four residents reviewed.
Failure to Maintain Sanitary and Safe Resident Environment
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to maintain a safe, clean, and homelike environment for residents. During observation rounds, several resident bathrooms were found with significant maintenance and cleanliness issues, including sinks loosely hanging from walls, toilets lacking proper seals with visible brown discoloration and holes at the base, bathroom floors with foul-smelling brown substances, ripped wallpaper, and separated door frames that compromised safe use. Additional concerns included brown stains on bathroom walls, missing drywall around exhaust fans, and marred walls under residents' TVs. These issues were identified in multiple rooms across both the east and west wing units. Further observations included the use of duct tape on chair railings near residents' beds and the presence of cobwebs, dead insects, and dirt between window screens and glass in resident rooms. Residents were present in the affected rooms at the time of the observations, and one resident reported a preference for keeping the window open, which revealed the unclean condition. The facility staff, including the Nursing Home Administrator, were made aware of these findings during the survey.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement complete, person-centered care plans to address the medical, nursing, mental, and psychosocial needs of several residents. One resident expressed a desire for dental extractions and was evaluated by a prosthodontist, who recommended full mouth rehabilitation and surgical extractions. Despite this, the resident's care plan did not address their dental issues, and there was no evidence of a care plan to meet these needs. Another resident was admitted to hospice care, but their care plan was not updated to reflect their hospice status, as confirmed by staff and medical record review. For residents assessed as high risk for elopement or wandering, the facility did not consistently include appropriate interventions in their care plans. One resident with a high elopement risk and a physician order for a Wander Guard device did not have a care plan focus for wandering or exit-seeking behaviors. Another resident's care plan was not updated to reflect changes in monitoring orders for their wander prevention band, despite documentation of behavioral monitoring and device checks in the medical record. Additionally, a resident with ataxia and muscle weakness, who was identified as requiring supervision and a smoking apron/blanket while smoking, was repeatedly observed smoking without supervision and without the required protective equipment. The care plan for this resident did not include the need for a smoking apron/blanket, as indicated in the smoking safety screen. Staff interviews confirmed that residents were non-compliant with the smoking policy, and the care plan did not fully address the resident's safety needs during smoking activities.
Failure to Store and Label Food According to Professional Standards
Penalty
Summary
Surveyors observed that the facility failed to store food in accordance with professional standards for food service safety. During observation rounds with a dietary aide, sealed bins of white flour, white rice, brown rice, and sugar were found in the kitchen's dry goods storage room with expired use-by dates clearly labeled on them. Specifically, the white flour, white rice, brown rice, and sugar all had use-by dates that had already passed. Additionally, in the kitchen's freezer, an opened bag of frozen pepperoni was found without any labeling to indicate when it was opened or when it would expire. Interviews with the Dietary Director and Regional Food Service Director confirmed the presence of expired dry goods and the unlabeled opened frozen pepperoni. The facility's Food Storage Chart policy was reviewed and states that expiration dates printed by the manufacturer apply until the food product is opened, after which specific timeframes for safe use are outlined. The policy also requires that opened food items be labeled with the date they were opened to determine expiration, which was not followed in the case of the pepperoni.
Failure to Promptly Distribute Resident Mail
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner, as required by facility policy. A complaint was reviewed indicating that a resident reported the Business Office was holding resident mail longer than appropriate. Interviews with the Business Office Manager revealed that when they began working at the facility, there was a backlog of undelivered resident mail due to the previous manager working remotely and not being present to distribute mail. The current Business Office Manager confirmed that they found and distributed the backed-up mail upon starting their position. Facility records, specifically the Resident Handbook, state that mail and other deliveries are to be promptly forwarded to residents.
Failure to Protect Residents' Property and Funds
Penalty
Summary
The facility failed to protect residents' property from loss in two separate incidents. In the first case, a resident's controlled pain medication, Oxycodone IR 5mg, was reported missing from the medication cart. The medication was received and signed for by an LPN, then handed off to other LPNs during shift changes. During these transitions, required counts of controlled medications were not performed, and the medication cart keys were exchanged without proper verification. The missing medication and its corresponding documentation were discovered the following morning when a nurse attempted to administer the medication and found it absent. In the second incident, a resident reported giving personal bank cards to a GNA to withdraw cash from an ATM. After returning the money and cards, the GNA requested and received a loan of $260 from the resident, with a verbal agreement to repay it. The GNA subsequently avoided contact and did not return the money as agreed. The incident was confirmed by facility staff during interviews.
Failure to Provide Written Bed-Hold Policy Notification Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to a resident or the resident’s representative prior to the resident’s transfer to a hospital. Medical record review showed that, before the resident was transferred in August 2024, there was no documentation indicating that the required written notification was given. Staff interviews confirmed that neither the resident nor the representative received the facility’s bed-hold policy paperwork or documentation before the transfer occurred.
Failure to Ensure Resident Privacy and Dignity During Care
Penalty
Summary
Facility staff failed to maintain a dignified and respectful environment for a resident during morning care. During observation rounds, the resident was found lying in bed with the bed raised to its highest position, uncovered, and with a yellow brief exposed. The privacy curtain was only partially drawn, allowing the resident to be visible to their roommate and anyone entering the room. When interviewed, the Geriatric Nursing Assistant acknowledged that the curtain should have been fully closed. The resident reported that staff never close the curtain, indicating a pattern of not ensuring privacy during care.
Inaccurate MDS Coding for Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident with a history of elopement and high risk for wandering. The resident, who had dementia and impaired safety awareness, was observed multiple times wearing a wander guard and walking around the facility. Documentation confirmed that the resident had previously eloped from the facility and was subsequently assessed as high risk for elopement, with a care plan and interventions in place, including the use of a wander guard and regular monitoring by nursing staff. Despite these documented risks and interventions, the quarterly MDS assessment did not accurately reflect the resident's wandering behavior or the use of a wander guard. The assessment failed to code for wandering in Section E and did not indicate the use of a wander guard in Section P. This inaccuracy was confirmed by the MDS Coordinator during an interview, acknowledging that the resident's behaviors and interventions were not properly documented in the MDS assessment.
Failure to Hold Timely Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to participate in their care planning process by not holding timely care plan meetings following comprehensive MDS assessments. Specifically, for one resident, care plan meetings were not conducted after quarterly and annual MDS assessments on three separate occasions, as confirmed by both record review and staff interviews. The care plan meetings are intended to involve the resident and/or their representative and are required to be held after each comprehensive assessment to summarize health conditions, care needs, and treatments. Interviews with the social worker revealed an ongoing issue with the timeliness of care plan meetings, with the staff member acknowledging that some meetings were overdue and in the process of being completed. Documentation reviewed by the surveyor confirmed the absence of care plan meetings for the resident following the specified MDS assessments, and no evidence was provided to show that the resident or their representative participated in the care planning process during those times.
Failure to Schedule Cardiology Follow-Up as Ordered
Penalty
Summary
A deficiency was identified when a resident, who had been admitted to the facility following a hospitalization for a stroke, did not have a cardiology follow-up appointment scheduled as ordered by the physician. The physician's order, dated 2/15/2025, specified that the resident should follow up with a cardiologist in 12 weeks. Upon review of the resident's electronic medical record and interviews with staff, it was found that there was no documentation of the appointment being scheduled within the required timeframe. Interviews with the Assistant Director of Nursing (ADON) and the unit clerk revealed that the process for scheduling appointments relies on the unit manager to inform the unit clerk of any required appointments, as the unit clerk does not have access to the electronic health record to view orders. The unit clerk only became aware of the need for the cardiology appointment on 4/22/2025 and scheduled it for a later date, well after the original order. This failure to ensure timely scheduling of the follow-up appointment resulted in the facility not meeting professional standards of care for the resident.
Failure to Administer Medication as Ordered
Penalty
Summary
A deficiency was identified when a resident did not receive their prescribed medication, Lacosamide 150mg, as ordered by the physician. Medical record review showed an active order for the resident to receive Lacosamide 150mg by mouth twice daily. During observation and medication cart review, it was found that the controlled substance blister pack contained 8 tablets, while the facility's controlled substance count sheet indicated there should have been 7 tablets remaining after the previous dose was reportedly administered the night before. Staff interview confirmed that the resident had not yet received the medication during the current shift and that the blister pack count did not match the count sheet, indicating a failure to administer the medication as ordered.
Failure to Accurately Reconcile Controlled Substance Medication
Penalty
Summary
The facility failed to accurately reconcile a resident's controlled substance medication, specifically Lacosamide 150mg, as required. Medical record review showed a physician's order for the resident to receive Lacosamide 150mg twice daily. On review of the medication cart and the resident's blister pack, there were 8 tablets present, while the controlled substance count sheet indicated there should have been 7 tablets remaining after the last documented administration. The count sheet showed that staff had signed off that the medication was administered and the count was correct, but this did not match the actual number of tablets in the blister pack. Further investigation revealed that the shift count sheet for the controlled substances was signed off by one staff member without completing the count with another nurse, as required during shift changes. Staff interview confirmed that the count was incorrect and that the medication had not been administered as documented. The staff member also acknowledged that the shift count sheet should not have been signed without a dual count at the time of shift change.
Failure to Provide Timely Dental Care for Resident
Penalty
Summary
Facility staff failed to ensure that a resident received necessary dental care. The resident expressed to staff a desire to have teeth extracted due to only being able to eat soft foods. The resident had previously been evaluated by a Prosthodontist, who recommended several surgical extractions and noted the resident's strong interest in dental implants. Despite this, there was no evidence that the recommended dental procedures were arranged or provided in a timely manner. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's dental needs. The unit manager acknowledged the resident's request but did not indicate any immediate action. The Administrator cited the high cost of the dental work and lack of insurance as reasons for the delay. The Business Office Manager was unaware of the dental issue until informed by the surveyor, indicating a breakdown in communication and coordination among staff regarding the resident's dental care needs.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for multiple residents. In several cases, cognitive assessments such as the Brief Interview for Mental Status (BIMS) were either incorrectly scored or not completed properly, leading to inconsistent documentation of residents' cognitive status. For example, one resident's BIMS score was entered as 99, indicating the interview could not be completed, yet the assessment showed the resident was able to answer questions, suggesting severe impairment. Additionally, smoking safety screens for these residents contained conflicting or missing information regarding cognitive loss and dexterity, with some questions left blank or answered inaccurately. Another deficiency was identified in the documentation of care provided, such as bathing. For one resident, the electronic medical record indicated a shower was given, while the corresponding shower sheet documented a bed bath instead, showing a discrepancy in the records. This inconsistency in documentation raises concerns about the accuracy of care records and the facility's ability to track the actual care provided to residents. Medication administration records also revealed deficiencies. A resident reported not receiving medications on time or at all, and a review of the electronic medical record and medication administration audit showed that medications were often administered and documented at times significantly later than ordered. Despite the medication administration record indicating that medications were given, the audit revealed delays and inconsistencies in the timing of administration and documentation. These findings demonstrate a failure to maintain accurate, timely, and complete medical records for residents, as required by professional standards.
Tracheostomy Tubing and Drainage Bag Found on Floor
Penalty
Summary
Surveyors observed that a resident with a tracheostomy had their extension tubing and drainage bag stretched across the floor and connected to their trach collar on multiple occasions. These observations occurred during several visits to the resident's room, where the oxygen delivery system was located along the wall and the tubing and drainage bag were seen in direct contact with the floor. Staff interviews confirmed that the tracheostomy extension tubing and drainage bag should not be touching the floor, yet the issue persisted even after it was brought to the attention of a unit manager. The infection preventionist also acknowledged that the tubing and drainage bag should not be on the floor.
Environmental Safety and Maintenance Deficiencies in Resident Bathrooms
Penalty
Summary
Surveyors determined that the facility failed to maintain a safe and comfortable environment for residents, as evidenced by observations made during facility rounds. Specifically, in two resident bathrooms, one was found to have a missing cove base at the bottom of the wall, and another had peeling paint on the floor. These deficiencies were directly observed by surveyors and subsequently brought to the attention of the Nursing Home Administrator and the Assistant Director of Nursing during staff interviews. No information was provided regarding the medical history or condition of the residents using these bathrooms at the time of the deficiency.
Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse, neglect, or misappropriation of resident property as required by regulations. In one instance, a resident reported that $20.00 was stolen from their room, but the facility did not follow up with the resident or report the incident to the Office of Health Care Quality or other appropriate agencies within 24 hours. Documentation showed that the facility was aware of the missing money on 10/03/24, but the incident was not reported until brought to the attention of staff by a surveyor several months later. Staff interviews confirmed that the report was not made in a timely manner. Additionally, the facility failed to report two separate allegations of abuse within the required two-hour timeframe. In one case, the Assistant Director of Nursing was notified of possible abuse at midnight, the Nursing Home Administrator was informed at 7am, but the initial report to the State Agency was not submitted until 3:15pm. In another case, the DON was made aware of an abuse allegation at 11am, the administrator at 11:30am, and the report was submitted at 4pm, all outside the mandated two-hour window. These failures were identified during a review of 19 facility-related incident reports, with three incidents not reported in accordance with regulatory requirements.
Failure to Prominently Post Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information in a prominent and readily accessible location for all residents and visitors on the Med Bridge unit. During observation rounds, it was noted that the staffing information was posted on the locked side of the unit, visible only through a slim window, making it difficult for most ambulatory residents and visitors on the unlocked side to view. This deficiency affected 17 out of 32 residents who resided on the unlocked portion of the unit. Staff confirmed that the information was not easily accessible to all residents and explained that staff verbally inform residents of their assigned caregivers at the start of each shift.
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Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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