Autumn Lake Healthcare At Alice Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 2095 Rockrose Avenue, Baltimore, Maryland 21211
- CMS Provider Number
- 215215
- Inspections on file
- 17
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Alice Manor during CMS and state inspections, most recent first.
Multiple residents reported long delays in call light response, inconsistent medication administration, and lack of assistance with basic needs due to insufficient staffing, especially during evening and night shifts. Staff confirmed that at times only one GNA was responsible for over 30 residents, resulting in incomplete care. Staffing records showed repeated instances of inadequate staffing levels, and the DON acknowledged these concerns.
Surveyors found multiple food items in the kitchen, refrigerator, freezer, and pantry that were either expired, unlabeled, or improperly stored, including expired hamburger buns, unlabeled frozen foods, and produce without dates. Staff interviews confirmed a lack of awareness regarding proper food labeling and discard timelines, and newly delivered bread was found without expiration dates and stored on the floor.
A soiled utility room containing used biohazard bags, needle/sharps containers, and oxygen equipment was found unlocked during a facility tour. The Maintenance Director was unable to secure the door when notified, and the DON acknowledged the safety concern regarding unsecured biohazard materials and sharps.
Facility staff did not adequately respond to grievances from two residents: one involving a staff member entering a resident's room after a distressing incident, and another regarding repeated loss of clothing following a change in laundry procedures. Documentation of grievances and facility responses was incomplete or missing, and residents' concerns remained unresolved.
Surveyors found that a resident with Huntington's disease and a high fall risk was repeatedly left in a Geri chair with unlocked wheels in busy areas, despite recent falls and involuntary movements. Additionally, another resident's fall mat was obstructed by an IV pole, even though staff safety rounds were supposed to keep such areas clear. Both deficiencies involved residents with documented fall risks and prior incidents.
A resident with orders for as-needed acetaminophen for mild pain did not have nonpharmacological pain management interventions documented on their care plan, MAR, or TAR. Both the Unit Manager and DON confirmed the lack of documentation, resulting in no evidence that nonpharmacological measures were considered before administering pain medication.
Three nursing staff members, including two GNAs and a CMA, were unable to correctly identify the location of the AED during staff interviews. Review of the facility's training materials showed no evidence that new or agency staff were educated on AED locations, leading to a deficiency in staff competency.
A CNA was found to be working without an active license and without documentation of required GNA training or testing. Leadership interviews confirmed there was no formal training program for CNAs to become GNAs, and the deficiency was validated by the DON.
Surveyors found that staff failed to accurately document the administration of controlled substances for two residents. In several instances, narcotics were signed out of the medication cart without corresponding entries in the MAR or without complete documentation of administration times. These discrepancies were confirmed by LPNs and brought to the attention of the DON.
Facility staff did not implement required behavior monitoring for residents receiving antipsychotic and antianxiety medications, and failed to ensure medications were administered as ordered. For example, a resident received Seroquel without behavior monitoring, another was given Tylenol for pain despite documentation of no pain, and a third resident on multiple psychotropic medications lacked required behavioral monitoring. Nursing leadership confirmed these monitoring tools and documentation were missing.
Two residents did not receive timely dental services as required. One resident requested dental care but never received it, with no documentation of a dental consultation since admission. Another resident with a chipped tooth had a referral for off-site evaluation, but no appointment was scheduled until after surveyor intervention. The DON confirmed these delays in dental care provision.
Staff failed to follow infection control protocols, including not wearing required PPE during medication administration and midline care for a resident on enhanced barrier precautions, and handling medications with bare hands. Additionally, isolation signage and supplies were not maintained as ordered for a resident with a midline catheter, and staff continued to document isolation precautions in the MAR even when orders were not active.
A resident was hospitalized after being administered methadone, a medication not prescribed to them, resulting in acute encephalopathy and respiratory failure. The incident involved an agency nurse who worked only one day at the facility, and the resident's roommate was prescribed methadone. The facility could not determine how the resident received methadone, leading to harm and hospitalization.
Facility staff failed to maintain a clean and safe environment on the first floor, as observed during a complaint survey. The area was cluttered with construction debris, unpackaged chairs, and dusty HVAC units. Windows were obstructed by cobwebs and dirt. The administrator cited ongoing improvements, while an EVS staff member was seen mopping, but bolts and screws remained on the floor.
The facility failed to report abuse allegations within the required two-hour timeframe for four residents. Incidents involved inappropriate language, physical abuse allegations, and inappropriate sexual interaction. Reports were submitted late, with delays ranging from several hours to days, as acknowledged by the facility's administration.
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving residents. Investigative files often lacked interviews with other residents or staff who might have witnessed the incidents. This pattern of incomplete investigations was consistent across various reported incidents, including verbal and physical abuse, and inappropriate behavior between residents. The facility's policy requires comprehensive investigations, but this was not adhered to in 15 out of 20 reviewed incidents.
A facility failed to protect residents from abuse, resulting in a sexual abuse incident involving a resident with severe cognitive impairment and another resident with dementia. Additionally, an LPN verbally abused two residents, one with schizoaffective disorder and another with major depressive disorder. The facility did not adequately monitor or supervise the residents involved, despite known behavioral issues and care plan directives.
A facility failed to notify a resident's representative in writing about the resident's transfer to a hospital. The medical record lacked evidence of such notification, and the facility's process did not include the required information. The NHA and DON acknowledged the deficiency during an interview.
Facility staff inaccurately documented a resident's medication status on an admission MDS, incorrectly coding the presence of unhealed pressure ulcers despite assessments showing no such wounds. This error was confirmed by the MDS Coordinator.
A facility failed to initiate a care plan for a resident with a history of substance abuse disorder, despite the resident receiving Methadone for addiction management. Upon admission, care plans were implemented for other conditions, but not for substance abuse. This oversight was confirmed by the former DON during an interview.
A resident with an abdominal surgical wound was admitted to the facility requiring a wound-vac, which was not applied until several days later due to the facility's failure to obtain the necessary supplies. The resident called 911 to return to the hospital for appropriate care. The DON confirmed the delay in obtaining the wound-vac.
A resident developed bed sores on the buttock area, and the facility failed to provide timely and appropriate care. An LPN noted a skin issue but did not document details, and there was a delay in following the physician's orders for wound care. The attending physician was not promptly informed, and the wound care physician, who visits weekly, identified multiple wounds during a delayed assessment.
A resident with cognitive impairment and mobility issues fell during the night shift, but the incident was not reported or investigated as required by facility policy. Despite the resident's care plan indicating a risk for falls, staff failed to communicate the incident, and no root cause analysis or preventive measures were implemented.
A facility failed to implement a trauma-informed care plan for a resident with a history of abuse by their significant other. Despite awareness of the resident's trauma history, no care plan with person-centered interventions was developed or documented. The deficiency was identified during a complaint investigation, with facility staff acknowledging the oversight.
A facility failed to limit a PRN order for Lorazepam to 14 days for a resident with epilepsy, lacking a specified duration or discontinuation date and without documented physician rationale for continuation. The Director of Nurses acknowledged the oversight, which was identified during a review of the resident's MAR and staff interviews.
A resident's lab specimen was collected without a physician's order, leading to an incorrect thyroid medication adjustment. The facility's DON believes the specimen was mislabeled, as the lab staff did not follow proper identification procedures.
Failure to Maintain Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of its residents, as evidenced by multiple resident and staff interviews, review of complaints, and staffing records. Several residents reported long delays in response to call lights, inconsistent medication administration times, and lack of assistance with basic needs such as feeding and hydration. One resident described waiting over an hour for help after activating the call bell at night, while another noted that agency staff appeared disengaged. Residents consistently expressed concerns about inadequate staffing, particularly during evening and night shifts. Staff interviews corroborated these concerns, with GNAs reporting that they were sometimes the only aide on a unit responsible for over 30 residents, leading to incomplete care tasks such as changing pads and repositioning residents. Staffing records confirmed that on multiple occasions, night shifts were staffed with only one GNA per unit, despite resident censuses ranging from 29 to 63. The DON acknowledged the staffing issues raised by both residents and staff. These findings demonstrate a pattern of insufficient staffing that directly impacted the timeliness and quality of care provided to residents.
Improper Food Labeling and Storage in Kitchen Areas
Penalty
Summary
During the initial kitchen tour, surveyors observed multiple instances of improper food labeling and storage. In the walk-in refrigerator, twelve 12-packs of hamburger buns were found to be expired, with various expiration dates. The walk-in freezer contained a bin labeled for discard with four packs of frozen waffles lacking expiration dates, an unlabeled and opened bag of green beans, a bag of sliced meat for sandwiches with a date, and open boxes of french toast and chopped carrots without expiration dates. Additionally, two bins contained a total of sixteen frozen chunks of unlabeled meats. In the produce refrigerator, eleven potatoes and nine green peppers were stored in plastic bins without labels or dates, and a box of celery was open to air and unlabeled. In dry storage, an opened five-pound bag of corn bread mix was found partially open to air with a date on it. A stack of newly delivered bread, including twenty-four bags of hot dog buns without expiration dates, was found sitting on the floor outside the walk-in refrigerator. Staff interviews confirmed the deficiencies. One staff member acknowledged the expired hamburger buns and was unaware of the proper discard timelines for frozen items, also confirming that all stored items should have been labeled. The food service director/Certified Dietary Manager agreed that it was concerning that staff were not aware of proper food storage timelines and verified that the new shipment of hot dog buns lacked expiration dates.
Soiled Utility Room Left Unlocked with Biohazard Materials
Penalty
Summary
During a recertification and complaint survey, it was observed that the soiled utility room on the first floor was left unlocked. This room contained used biohazard bags, used needle/sharps containers, used oxygen equipment, and trash. The Maintenance Director was informed of the unlocked door and attempted to lock it but was unable to resolve the issue at that time. The Director of Nursing was also notified of the unlocked room and acknowledged the safety concern regarding the presence of biohazard materials and sharps in an unsecured area. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Failure to Adequately Address Resident Grievances
Penalty
Summary
Facility staff failed to provide adequate responses to resident grievances, as evidenced by two of three grievance records reviewed. In one instance, a resident reported distress after a staff member caused the death of a plant that had sentimental value. The resident requested that the staff member not enter their room, but the staff member continued to enter to care for the roommate. There was no grievance form or documentation of the facility's response to this incident, aside from the staff member's written statement. The facility was unable to provide additional documentation such as a supervisor's order or follow-up regarding the resident's request and grievance. In another case, a resident reported repeated loss of clothing after the facility changed its laundry process to an external contractor. The resident stated that the issue had been reported to the social worker and management, but only two grievance forms were found, both from earlier dates, and no form was found for the most recent incident until after the surveyor's intervention. The resident continued to express frustration about missing clothing, and the facility acknowledged ongoing issues with the laundry contractor and delays in resolving residents' concerns.
Failure to Prevent Accident Hazards and Ensure Safe Environment for Residents at Fall Risk
Penalty
Summary
Surveyors identified deficiencies related to accident hazards and inadequate supervision for residents at risk of falls. One resident with Huntington's disease, who was at high risk for falls and had a recent history of falling, was repeatedly observed in a Geri chair with unlocked wheels in busy areas of the facility. Despite the resident's involuntary movements and documented fall risk, the Geri chair was not consistently secured, and there were no specific care plan interventions addressing the safe use and placement of the Geri chair for this resident. The resident experienced multiple falls requiring hospital transfers during the survey period. In a separate incident, another resident identified as a fall risk had an IV pole stored on top of their safety fall mat in their room. This obstruction was observed on multiple occasions during the survey, despite the resident's documented history of falling. Staff interviews confirmed that safety rounds were intended to ensure fall mats were clear of objects, but the IV pole remained on the mat until it was pointed out by surveyors and subsequently removed by staff.
Failure to Document Nonpharmacological Pain Management Interventions
Penalty
Summary
Facility staff failed to document or initiate nonpharmacological pain management interventions for a resident who had an order for as-needed acetaminophen for mild pain. The resident's care plan identified a potential for altered comfort due to acute illness and chronic morbidities, with interventions including administration of analgesic medication as ordered and regular pain assessments. However, there was no documentation of nonpharmacological pain interventions on the care plan, Medication Administration Record (MAR), or Treatment Administration Record (TAR). During interviews, both the Unit Manager and the Director of Nursing confirmed that nonpharmacological pain interventions were not documented in the resident's medical record, acknowledging that this documentation should have been present. The absence of this documentation meant there was no way to validate that nonpharmacological measures were considered or attempted prior to administering pain medication.
Nursing Staff Lacked Education on AED Location
Penalty
Summary
Facility staff failed to ensure that all nursing staff were educated on the location of the Automated External Defibrillator (AED). During a recertification and complaint survey, interviews were conducted with eleven nursing staff members, including agency and facility staff. Three of these staff members, specifically two Geriatric Nursing Assistants (GNAs) and one Certified Medication Aide (CMA), were unable to correctly identify the location of the AED. One GNA stated they had never been shown the AED location, another incorrectly believed it was on the medication cart, and the CMA initially thought it was in the medication room before being corrected. A review of the facility's Welcome Training packet for nursing staff revealed that it did not include any information or evidence of training regarding the location of the AED for new or agency staff. This lack of education and orientation contributed to the deficiency, as not all staff were prepared to respond appropriately in an emergency situation requiring the use of the AED.
Failure to Ensure CNA Training and Active Licensure
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) received the required training to become a Geriatric Nursing Assistant (GNA) within the mandated 4-month timeframe. Record review showed that one CNA, who had been employed for more than four months, did not possess an active CNA license, and there was no documentation indicating that she had completed the necessary training or testing to become a GNA. The Maryland Board of Nursing license verification confirmed that her CNA license had expired and her status was listed as pending. Interviews with facility leadership revealed that there was no specific training program in place for CNAs to transition to GNAs, and the staff member in question was the only CNA currently working in the building. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both acknowledged the lack of a formal training process, and the Human Resources Director confirmed the absence of a special training course for CNAs to become GNAs. The deficiency was validated by the DON during the survey.
Failure to Ensure Accurate Documentation and Administration of Controlled Substances
Penalty
Summary
Surveyors identified that the facility failed to ensure proper administration and documentation of controlled substances for two residents. For one resident, the controlled drug administration record for Oxycodone showed five instances where the medication was signed out of the medication cart, but there was no corresponding documentation in the Medication Administration Record (MAR) to indicate that the medication was administered or that there was a documented need for it. The dates and times on the controlled drug record did not match the MAR, and this discrepancy was confirmed by the LPN present during the review. For another resident, the controlled drug administration record for Tramadol showed that while dates were documented for when the medication was removed, the times were missing. This lack of complete documentation was also confirmed by the LPN responsible for the medication cart. The Director of Nursing acknowledged that her expectation was for the controlled drug administration records to match exactly with the MAR, and she was made aware of these findings during the survey.
Failure to Monitor Behaviors and Administer Medications as Ordered
Penalty
Summary
Facility staff failed to implement required behavior monitoring for residents prescribed antipsychotic and antianxiety medications, as evidenced by the absence of behavior monitoring logs or tools in the clinical records of multiple residents. For one resident with a diagnosis of bipolar disorder and a history of behavioral issues, Seroquel was administered as ordered, but there was no documentation of behavior monitoring as required by the care plan and physician order. Both the Unit Manager and DON confirmed that behavior monitoring tools should have been present in the electronic health record but were not. Another resident was prescribed Tylenol as needed for pain, with orders specifying administration for pain levels of 1-5 on a 0-10 scale. However, staff administered Tylenol even when the pain scale documented a score of 0, indicating no pain. Additionally, there were no interventions documented for pain levels of 6-10, and the Assistant DON acknowledged these discrepancies when shown the medication administration records. A third resident with multiple psychiatric diagnoses, including bipolar disorder and schizophrenia, was prescribed several psychotropic medications. The care plan required monitoring and documentation of mood and behavioral symptoms, but there was no evidence of a behavioral monitoring tool or related documentation in the resident's records. Both the Unit Manager and DON confirmed that this monitoring was not initiated as required.
Failure to Provide Timely Dental Services to Residents
Penalty
Summary
The facility failed to ensure that residents requiring dental services received necessary and recommended care in a timely manner. One resident reported requesting dental services but did not receive them, with facility staff indicating that insurance coverage was an issue. A review of this resident's medical record revealed no documentation of any dental consultation since admission, and the Director of Nursing confirmed that no dental services had been provided to this resident. Another resident reported having a chipped tooth and was waiting for a dental appointment. Medical records showed a referral and examination note indicating the need for off-site evaluation and treatment, but there was no evidence that an appointment had been scheduled until after surveyor intervention. The Director of Nursing acknowledged that the appointment was only made following the surveyor's involvement, confirming the delay in providing necessary dental care.
Failure to Implement and Maintain Infection Control and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff during medication administration and the maintenance of isolation precautions. Specifically, a nurse administered medications and provided midline catheter care to a resident on enhanced barrier precautions (EBP) without donning an isolation gown, despite signage indicating the need for EBP and a care plan requiring staff to follow EBP protocols. The nurse acknowledged awareness of the requirement but cited the absence of gowns in the isolation cart as the reason for non-compliance. Another nurse was observed preparing medication for a resident with a gastric feeding tube by breaking open a capsule with bare hands, rather than using gloves. The nurse stated she was instructed not to wear gloves in the hallway, but also acknowledged that medications should not be handled with bare hands. The Director of Nursing confirmed the expectation that medication preparation occurs outside the resident's room without gloves, but that gloves should be used when direct contact with medications is necessary, and this should occur inside the resident's room. Additionally, the facility failed to maintain required isolation precautions for a resident with a midline catheter and orders for both contact/droplet and enhanced barrier precautions. Observations revealed the absence of isolation signage and an isolation cart outside the resident's room, despite active orders documented in the medical record. Staff continued to sign off on isolation precautions in the medication administration record even when the orders were not in place, and there was a lapse in re-establishing precautions after the midline was replaced.
Resident Hospitalized Due to Medication Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by a resident being administered methadone, a medication that was not prescribed to them, resulting in hospitalization. The incident involved a resident who was admitted to the hospital with acute encephalopathy, bradycardia, and acute hypercapnic respiratory failure, and tested positive for methadone despite not being on a methadone treatment program. The resident was managed for opioid intoxication, and the facility's Director of Nurses confirmed that the resident was not on methadone treatment. The incident occurred when the resident was found lethargic, sweating profusely, and with high blood pressure, leading to their transfer to the emergency room. The resident's medical records showed that they were administered acetaminophen and an inhaler on the day of the incident, with no documentation of methadone administration. An investigation revealed that the resident's roommate was prescribed methadone, and the nurse assigned to the resident that day was an agency nurse who only worked at the facility on that day. The facility was unable to determine how the resident received methadone, but the nurse involved was suspended during the investigation. The facility's investigation included reviewing medical records and obtaining statements from staff, but they could not substantiate that the resident was inadvertently administered methadone by the assigned nurse. The facility's failure to ensure the resident was free from significant medication errors resulted in harm and hospitalization.
Removal Plan
- An audit of all resident's identification to assure all residents were validated with 2 identifiers per protocol.
- Actions to prevent occurrence/recurrence implement: All applicable facility policies and procedures (medication administration) were reviewed.
- Re-educated licensed nurses on facility policies regarding medication administration as well as medication administration identification and transcription order guidelines. All nurses were educated and validated by test.
- Educated the admission team on the importance of having the resident identifiers in place upon admission.
- Educate all orientees as part of the new hire process on medication administration identification and transcription orders.
- The DON implemented a QAPI AD-Hoc to gather and process information from the audit with findings reported at the monthly QAA meeting for a minimum of 3 months.
- Inservice Training Guide for Regulation F760 reviewed.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents on the first floor, as observed during a complaint survey. The complaint alleged that the facility was very unclean. Observations revealed a painting and an outdated activity calendar on the floor, orange buckets with fish aquarium equipment, construction tools and debris, dusty HVAC units with cobwebs and debris, and unpackaged chairs stacked in the room. Additionally, large pane windows were covered with cobwebs, dirt, and leaves, obstructing the view. During an interview, the facility administrator mentioned ongoing improvements and the relocation of the fish tank due to construction. An EVS staff member was observed mopping the floor, but bolts and screws were found on the floor, indicating incomplete cleaning efforts.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency within the required timeframe of two hours for four residents. Resident #28, who had a history of schizoaffective disorder and anxiety, was involved in an incident where an LPN used inappropriate language towards them. The incident was reported to the Assistant Director of Nursing (ADON) the following day, which was beyond the two-hour reporting requirement. The ADON and the Administrator acknowledged the delay in reporting. Resident #41, diagnosed with schizophrenia, alleged that a staff member had physically abused them. The incident was reported four days after it was initially disclosed to a Certified Medicine Aide (CMA), who did not immediately recognize it as abuse. The Administrator confirmed that the report was submitted late and should have been reported within two hours of the allegation. Residents #37 and #39 were involved in an incident of inappropriate sexual interaction, which was witnessed by staff. The report to the State Survey Agency was submitted over two hours after the incident was observed. Additionally, Resident #37 was involved in another incident where a CMA made a threatening comment, and the report was submitted over 24 hours later. The Administrator and Former Director of Nursing acknowledged the delays in reporting these incidents.
Inadequate Investigation of Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving residents. In several cases, the investigative files lacked interviews with other residents who might have witnessed the incidents or had relevant information. For instance, in the case of a resident who reported being kicked by a Geriatric Nurse Aide, the facility did not interview other residents to assess the extent of the alleged abuse. Similarly, when a resident reported being hit by their roommate, the facility did not conduct interviews with other residents on the same hall to determine the scope of the incident. In another instance, a resident reported an injury of unknown origin, but the facility's investigation did not include interviews with other residents or assessments of the mental status of residents on the same hall. Additionally, when a Registered Nurse accused a certified medication aide of threatening a resident, the facility's investigative file did not contain interviews with other residents or staff who might have witnessed the incident. This pattern of incomplete investigations was consistent across multiple reported incidents, including allegations of verbal abuse, physical abuse, and inappropriate behavior between residents. The facility's policy on abuse, neglect, and exploitation requires immediate and thorough investigations, including identifying and interviewing all involved persons and documenting the investigation comprehensively. However, the facility repeatedly failed to adhere to these procedures, as evidenced by the lack of resident interviews, staff interviews, and physical assessments in the investigative files. This deficiency in the investigation process was noted in 15 out of 20 facility-reported incidents reviewed by the survey team, involving multiple residents and various types of alleged abuse and neglect.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving both verbal and sexual abuse. Resident #37, who had a history of bipolar type schizoaffective disorder and severe cognitive impairment, was involved in a sexual abuse incident with Resident #39, who had severe cognitive deficits and dementia. Despite Resident #37's care plan indicating a potential for inappropriate behavior, staff failed to document or monitor the resident's behavior adequately. On March 16, 2023, Resident #37 was observed exposing their genitals and using Resident #39's hand to touch them, an act witnessed by staff who intervened immediately. In another incident, verbal abuse was reported involving LPN #37 and two residents, Resident #27 and Resident #28. Resident #28, who had intact cognition but suffered from moderate depression and schizoaffective disorder, was verbally abused by LPN #37, who told the resident to "shut up" and threatened them. This incident was witnessed by GNA #36, who reported it to the Assistant Director of Nursing. Resident #27, who shared a room with Resident #28 and had a history of major depressive disorder, was also verbally abused by LPN #37, who told them to "shut up and mind your own business." The facility's failure to protect residents from abuse is evident in the lack of adequate supervision and monitoring of Resident #37, despite known behavioral issues, and the inappropriate conduct of LPN #37 towards Residents #27 and #28. These incidents highlight significant lapses in the facility's adherence to its own policies on abuse prevention and resident protection, as well as a failure to ensure a safe environment for all residents.
Failure to Notify Resident's Representative of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident's representative regarding the resident's transfer to a hospital. This deficiency was identified during a review of a complaint where the complainant reported not being notified of the transfer. The medical record of the resident, who was admitted to the facility in September 2022 and transferred to the hospital in October 2024, lacked evidence of written notification to the resident's representative at the time of transfer or shortly thereafter. During an interview, the Nursing Home Administrator (NHA) and Director of Nurses (DON) indicated that the Admissions department was responsible for sending the transfer notification and documenting it in the resident's medical record. However, no documentation was found in the resident's record to confirm that the notification was sent. The NHA acknowledged that the facility's process did not include the required notification information, as the summary of the change in condition did not meet the necessary criteria.
Inaccurate MDS Coding for Resident's Pressure Ulcer Status
Penalty
Summary
The facility staff failed to accurately document a resident's medication status on an admission Minimum Data Set (MDS) for one resident during a complaint survey. Specifically, the MDS was incorrectly coded to indicate the presence of unhealed pressure ulcers, despite nursing and physician assessments showing no evidence of such wounds upon the resident's admission. This discrepancy was confirmed during an interview with the facility's MDS Coordinator, who acknowledged the incorrect coding on the admission MDS.
Failure to Initiate Care Plan for Substance Abuse Disorder
Penalty
Summary
The facility staff failed to initiate a care plan for a resident with a history of substance abuse disorder. This deficiency was identified during a complaint survey involving a resident who was receiving Methadone for substance abuse disorder. Upon admission in February 2024, the nursing staff implemented care plans for various conditions such as seizure disorder, potential for malnutrition and dehydration, self-care deficit, and fall risk. However, they did not create a care plan specifically addressing the resident's substance abuse disorder, despite the resident being administered Methadone for addiction management. This oversight was confirmed during an interview with the former director of nurses, who acknowledged that the resident was receiving Methadone for addiction, not pain management.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to ensure that a resident received necessary services to promote the healing of a surgical wound. A resident was admitted with an abdominal surgical wound that required a wound vacuum (wound-vac) to be applied upon admission. However, the facility did not obtain the wound-vac and necessary supplies in time, resulting in the wound-vac not being applied until several days after admission. The resident called 911 to be transported back to the hospital due to the lack of appropriate wound care. The facility's Director of Nursing confirmed that the wound-vac was not obtained prior to the resident's admission, and the wound-vac was eventually applied days later after the supplies arrived.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident received appropriate services to promote the healing of a pressure ulcer. This deficiency was identified during a complaint survey, where it was found that a resident developed bed sores on the buttock area. A review of the resident's clinical record revealed that a Licensed Practical Nurse (LPN) documented a skin issue on the sacral area but did not provide a description or measurements of the wound. The attending physician's orders to cleanse the wound and apply medihoney were not followed until the day after the orders were given, indicating a delay in treatment. Interviews with the resident's attending physician and wound care physician revealed further issues in the care process. The attending physician was not notified of the sacral wound in a timely manner, and the wound care physician, who visits the facility only once a week, was not able to assess the resident until several days after the wound was identified. During the assessment, the wound care physician documented multiple wounds, including two pressure wounds on the ischium and a lymphademic wound on the leg, highlighting a lack of timely and effective wound management for the resident.
Failure to Investigate Resident Fall and Implement Preventive Measures
Penalty
Summary
The facility failed to investigate a fall, determine the root cause, and implement interventions to prevent further falls for a resident. The resident, who had a medical history of degenerative disease of the nervous system, generalized muscle weakness, abnormalities of gait and mobility, and dementia, was found on the floor by Geriatric Nursing Assistants (GNAs) during the night shift. Despite the facility's policy requiring an incident report and investigation after a fall, the incident was not reported to the nursing staff, and no investigation was conducted to determine the cause of the fall. The resident's care plan indicated a risk for injury due to falls, with interventions to encourage the resident to ask for help and ensure safety measures were in place. However, the incident report revealed that the resident's roommate alleged an altercation, which may have contributed to the fall, but this was not investigated. Interviews with staff indicated a lack of communication and failure to follow protocol, as the fall was not reported to the nurse, and no incident report was completed. The Director of Nursing and other staff acknowledged the oversight, but no explanation was provided for the failure to investigate the fall.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to provide appropriate interventions for a resident with a history of trauma, as identified in a complaint investigation. The resident, who had complex medical conditions including Parkinson's, Schizophrenia, and depression, was admitted to the facility for long-term care. Upon readmission after a hospitalization, it was noted that the resident had a history of trauma related to alleged abuse by their significant other. Despite this, the facility did not develop or implement a care plan with person-centered, non-pharmacological approaches to address the resident's trauma history. The deficiency was highlighted during a review of the resident's medical record, which lacked evidence of a trauma care plan. Interviews with facility staff, including the Director of Social Work and the Director of Nurses, confirmed awareness of the resident's history of abuse and the significant other's restriction from visiting. However, no documentation or care plan was found to address the resident's trauma, leading to the deficiency finding. The Nursing Home Administrator and other facility leaders were informed of these concerns, acknowledging the lack of a care plan for the resident's trauma history.
Failure to Limit PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication by not limiting a PRN order for Lorazepam to 14 days. The medication was prescribed for a resident with epilepsy to manage uncontrolled seizures, with instructions to administer 2 mg intramuscularly every 5 minutes as needed, up to a maximum of three doses. However, the order did not specify a duration or discontinuation date, and there was no documented rationale from the physician for continuing the order beyond the 14-day limit. The deficiency was identified during a review of the resident's November 2024 Medication Administration Record (MAR) and was further confirmed through staff interviews. The Director of Nurses acknowledged the concern, recognizing that psychotropic medications prescribed as needed require a stop date. This oversight was evident for one of the 23 residents reviewed for complaints, highlighting a lapse in adhering to regulatory requirements for psychotropic medication management.
Unauthorized Lab Specimen Collection
Penalty
Summary
The facility staff obtained a laboratory specimen from Resident #14 without a physician's order, which was identified during a complaint survey. Resident #14's medical record showed a laboratory result indicating normal TSH and Free T4 levels, but the specimen was collected without an order. The resident had been readmitted to the facility with instructions from the physician to obtain a TSH level on a specific date. However, the laboratory staff collected a blood specimen on a different date and reported an abnormal TSH level, leading to an adjustment in the resident's thyroid medication. The physician had also instructed the staff to obtain further thyroid studies in six weeks, but the resident was sent to the hospital due to a change in condition and did not return, subsequently passing away at the hospital. The Director of Nurses (DON) stated that the contracted laboratory representative confirmed a physician's order for the thyroid studies, but could not identify which resident the specimen was obtained from on the incorrect date. The DON believed that the laboratory staff collected the specimen from a different resident and mislabeled it with a pre-printed label. The facility's laboratory policy requires phlebotomists to verify patient identity using two identifiers and to contact a nurse if the resident is unable to speak or lacks a wristband, documenting the nurse's name on the requisition. This procedure was not followed, leading to the deficiency.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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