Autumn Lake Healthcare At Ballenger Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Frederick, Maryland.
- Location
- 347 Ballenger Drive, Frederick, Maryland 21701
- CMS Provider Number
- 215001
- Inspections on file
- 18
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Ballenger Creek during CMS and state inspections, most recent first.
Surveyors found expired milk, unlabeled veal meat, and improperly labeled cold salad in facility refrigerators, along with a dirty snack fridge described as 'disgusting' by an LPN. Several residents reported receiving cold food, and a review of temperature logs showed missing entries for multiple meals, despite staff being expected to check and reheat food as needed.
The facility did not provide required education or offer the 2024-2025 COVID-19 vaccine to most staff, as shown by missing documentation in five out of six employee files and confirmed by interviews with the Infection Preventionist and the Nursing Home Administrator.
A resident admitted to hospice care did not have a Significant Change in Status MDS assessment completed within the required 14-day period. Medical record review showed that the assessment was finalized after the mandated timeframe, despite the presence of a hospice order, resulting in noncompliance with federal assessment requirements.
Surveyors identified that MDS assessments were inaccurately recorded for four residents, including errors such as documenting restraint use that did not occur, failing to note impaired range of motion after surgery, recording an incorrect discharge destination, and omitting upper extremity impairment despite therapy documentation. Staff interviews confirmed these inaccuracies and attributed some errors to delays in receiving therapy data.
Facility staff did not develop or implement individualized care plans for several residents, resulting in unmet needs related to activity preferences, lack of accessible materials for a visually impaired resident, and inadequate supervision during meals for a resident with severe dysphagia. These deficiencies were identified through interviews, observations, and review of care plans and MDS assessments.
Several residents with varying cognitive abilities did not receive individualized activities aligned with their preferences, as required assessments and care plans were incomplete or not followed. Documentation of activity participation and refusals was lacking, and residents reported limited or no engagement in activities, with some not being offered preferred options such as reading materials or outdoor time. Staff were unable to provide records to support that activities were offered or refused.
A resident with anxiety and on dialysis did not consistently receive Ativan as ordered, with missing documentation for several evening doses and instances where the wrong dosage was administered. Staff documented giving Ativan on the MAR, but drug control sheets did not confirm removal of the medication on multiple dates, and on some occasions, the resident received a higher dose than prescribed due to duplicate orders and incorrect administration.
Staff did not accurately document the administration of a controlled medication for a resident, with missing entries on drug control sheets for several dates. Another resident requiring supervision during meals was observed eating unsupervised in bed, despite documentation stating otherwise and without recording the resident's refusal to get out of bed. Additionally, documentation for personal hygiene and repositioning was incomplete for multiple residents, including one who reported not receiving a shower despite records indicating otherwise and no supporting documentation found.
Surveyors identified multiple infection control deficiencies, including staff failing to perform hand hygiene between glove changes, improper handling of clean gloves, and not wearing required gowns during high-contact care for a resident on Enhanced Barrier Precautions. Additionally, soiled linen bins in the laundry area were found uncovered and unlabeled, with clean laundry bins brought into the soiled area, contrary to infection prevention protocols.
The facility did not conduct thorough investigations into multiple abuse allegations, including incidents where residents reported being struck, pushed, inappropriately touched, or roughly handled by staff. Investigation files were incomplete, lacked proper documentation, and failed to identify alleged perpetrators or include necessary follow-up, resulting in insufficient responses to serious resident concerns.
Multiple dependent residents did not consistently receive required ADL care, including incontinence care, bathing, and feeding. Some residents were left in soiled linens or went extended periods without showers or grooming, despite being fully dependent on staff. Documentation was often incomplete or inaccurate, with care sometimes recorded as provided when residents denied receiving it, and required supporting records were missing. Staff interviews confirmed delays and omissions in care delivery.
A deficiency occurred when a Hoyer lift, essential for resident mobility assistance, was found to be inoperable due to dead batteries. A grievance was filed and validated by both staff and the county ombudsman, with facility leadership aware of the issue. No harm resulted to the resident involved.
A resident who had difficulty chewing facility food relied on family to bring in outside food, which was later found missing from the unit refrigerator. Staff interviews revealed inconsistent application of the facility's food labeling policy, with dietary staff discarding items lacking an expiration date, while nursing staff only required the date of placement. This inconsistency led to the resident's food being discarded and unavailable.
A resident was observed on two occasions seated in a wheelchair at bedside with the call bell tied to the opposite bed rail, making it inaccessible. Staff confirmed the call bell was out of reach and only repositioned it after being prompted by surveyors. Inaccessible lighting controls were also noted in all rooms observed.
A resident with decision-making capacity did not have a health care advance directive on file, despite documentation indicating otherwise. Staff had recorded the presence of an advance directive during admission and in a social service assessment, but only a non-health care-related power of attorney document was found. The Social Service Designee confirmed the absence of the correct document and that the family was not informed about the issue.
Two residents experienced deficiencies in environmental cleanliness and personal care. One resident's room remained dirty for an extended period, with debris and dried fluids on the floor, despite daily cleaning protocols. Another resident, fully dependent on staff, had visibly soiled and unchanged bed linens for several days, including a urine-soaked incontinence pad, contrary to the facility's stated linen change schedule.
A resident reported that the leg rests from their personal wheelchair were missing for about a month. Although the physical therapist and a nurse were aware and attempted to locate the items, the facility did not document the concern or initiate the required grievance process, as confirmed by the Director of Rehabilitation.
A resident's admission MDS assessment was completed four days past the required regulatory deadline. The assessment, which should have been finalized within 14 days of admission, was instead completed on day 18, as confirmed by the MDS Coordinator. This delay resulted in the facility failing to maintain timely and accurate assessment records for care planning.
A resident who had both quarterly and significant change MDS assessments did not have documented interdisciplinary care plan meetings following these assessments. Review of medical records and staff interviews confirmed that no care plan meetings were held for this resident during the relevant period.
The facility did not ensure that care plan interventions to prevent accidents were consistently implemented or documented. Two residents with fall risk did not have required floor mats in place despite staff documentation stating otherwise, and another resident at risk for elopement had no documentation of required wander guard functionality checks after a change in orders. These deficiencies were confirmed through observation and staff interviews.
Two residents did not receive pain management services as ordered: one was left without access to PRN oxycodone due to lack of medication supply, and another received PRN pain medication without documented pain assessments or attempts at non-pharmacological interventions as required by provider orders.
A resident with anxiety, insomnia, and moderate depression did not receive consistent behavioral health services or proper documentation of prescribed Ativan administration. Despite recommendations for ongoing therapy and medication, there was no evidence of follow-up behavioral health visits or confirmation that all ordered doses of Ativan were given, resulting in a deficiency in behavioral health care.
A pharmacist did not identify significant medication errors for a resident prescribed Ativan, including missed doses and extra doses, due to incomplete review of the medical record. The errors were linked to duplicate active orders and discrepancies between the Medication Administration Record and drug control sheets, which the pharmacist did not fully reconcile during the monthly drug regimen review.
A resident with severe cognitive impairment was the subject of an abuse allegation reported by a family member to a nurse, who documented the concern. There was a two-day delay before the DON submitted the initial report to authorities, despite the DON stating the concern was addressed immediately.
A resident with a diabetic foot wound and recent amputation did not receive consistent Negative Pressure Therapy (VAC) as ordered, with multiple days lacking documentation or assessment of the device's functioning. Nursing staff failed to monitor and document the VAC therapy, and the wound specialist and DON confirmed that care and documentation were substandard, resulting in deterioration of the surgical site.
Deficient Food Storage, Labeling, and Temperature Monitoring
Penalty
Summary
Surveyors observed multiple failures in food storage and preparation practices within the facility. In the walk-in refrigerator, nine cartons of milk were found with expiration dates that had already passed. In the walk-in freezer, ten bags of veal meat were stored in a paper box without any label indicating the expiration or use-by date, and staff acknowledged the lack of proper labeling. Additionally, a plate of cold salad in the LTC unit snack refrigerator was not labeled with the date it was prepared or a use-by date. The same refrigerator contained various food items and was found to be dirty, with a brown paper in a brownish liquid, and staff described its condition as "disgusting and dirty." The unit manager stated that housekeeping typically cleaned the refrigerator monthly. Residents reported that their food was usually cold by the time it was served. A review of food service temperature logs revealed multiple instances where required temperature checks were missing for various meals on several dates. The Regional Training manager confirmed that staff were expected to check food temperatures before each meal service and reheat food if temperatures were below acceptable levels, but the logs did not reflect consistent compliance with this protocol.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that staff were educated about and offered the 2024-2025 COVID-19 vaccine, as required. During a review of six employee files, documentation was missing for five staff members regarding both education and the offer of the most recent COVID-19 immunization. Interviews with the Infection Preventionist revealed a lack of awareness about the annual requirement to provide education and offer the vaccine, resulting in no staff being educated or offered the vaccine for the current year. Only one immunization record was available among the files reviewed. The Nursing Home Administrator also confirmed that she was not previously aware of the annual requirement.
Failure to Complete Timely Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required 14-day timeframe for a resident who was admitted to hospice care. Record review and staff interviews confirmed that the resident was admitted to hospice with an effective order date of 4/21/25, but the Significant Change in Status MDS assessment was not completed and signed until 5/7/25, which was outside the mandated period. This deficiency was identified during a survey and was based on the review of medical records and provider orders for the resident involved in hospice care. The MDS is a federally mandated assessment tool used to guide care planning decisions, and timely completion is required when there is a significant change in a resident's status, such as admission to hospice. The failure to complete the assessment within the specified timeframe was evident in the documentation reviewed for the resident.
Inaccurate MDS Assessments Documented for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded for four residents. In one case, a resident's MDS indicated the use of a limb restraint, but both the resident and family denied any restraint use, and staff confirmed the facility was restraint-free. Another resident's MDS failed to document impaired range of motion (ROM) in the right lower extremity following hip surgery, despite therapy records indicating impairment. Additionally, the completion date for this resident's MDS was inaccurately recorded, as some sections were finalized after the documented completion date. A third resident's discharge MDS incorrectly stated the resident was discharged to an acute hospital, when in fact the resident was discharged home. In another instance, a resident with a history of neck fractures and documented bilateral upper extremity ROM impairment in therapy evaluations was inaccurately recorded in the MDS as having no impairment. Staff interviews revealed that delays in receiving therapy data contributed to these inaccuracies, and staff responsible for MDS completion acknowledged the errors.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
Facility staff failed to develop and implement comprehensive, person-centered care plans for multiple residents, as evidenced by surveyor observations, medical record reviews, and interviews. For one resident who is legally blind, the care plan did not address their stated preferences for accessible reading materials, music, religious services, or being around pets, despite these being identified as important in the Minimum Data Set (MDS) assessment. The care plan also failed to account for the resident's need for assistance with reading activity calendars due to their visual impairment. Another resident admitted for rehabilitation services reported being unaware of available activities and only occasionally encountering them by chance. Review of this resident's care plan revealed that no activities care plan was in place, and staff confirmed that required MDS sections had not been completed or implemented into the care plan. A third long-term resident expressed a desire for more varied activities, stating that only bingo was offered, which did not align with their preferences documented in the MDS for reading materials and outdoor time. The care plan for this resident only included group activities like bingo, failing to match the resident's stated interests. A fourth resident with severe dysphagia and a history of stroke was observed eating unsupervised on multiple occasions, despite care plan directives for aspiration precautions, one-person assistance, and supervision during meals. The resident was also observed eating in bed, contrary to care plan instructions to be out of bed for meals, and refusals of care were not documented as required. Staff interviews confirmed confusion regarding supervision expectations and inconsistencies between care plan documentation and observed practices.
Failure to Provide Resident-Centered Activities and Document Participation or Refusals
Penalty
Summary
The facility failed to implement an ongoing, resident-centered activities program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, as evidenced by the experiences of four residents. One resident, who is legally blind and has resided at the facility for over a year, expressed that access to reading materials, music, animals, and religious services was very important. However, there was no documentation of activity participation or 1:1 visits for most of the reviewed period, and staff could not provide records of activity refusals. The care plan for this resident included interventions such as 1:1 visits and assistance to activities, but these were not documented as being carried out. Another resident, admitted for rehabilitation and with moderately impaired cognition, reported being unaware of activities in the facility. The resident's MDS assessment did not include the required activity preferences section, and there was no activities care plan in place. Activity attendance records showed only one documented activity, and staff could not provide documentation of refusals despite stating that the resident often refused activities. Similarly, a long-term resident with intact cognition reported rarely getting out of bed and not receiving in-room activities. The annual MDS assessment for this resident also lacked the required activity preferences section, and there was no documentation of activity participation or refusals. A fourth resident, also with intact cognition, expressed a desire for more varied activities beyond bingo and indicated a preference for reading materials and outdoor time. The care plan for this resident focused on group activities and bingo, which did not align with the resident's stated preferences. Observations confirmed the absence of reading materials in the resident's room, and activity records did not show that reading materials or outdoor opportunities were offered. These findings were confirmed by interviews with staff and the DON, and no further information or documentation was provided by the facility prior to the end of the survey.
Failure to Prevent Significant Medication Errors in Ativan Administration
Penalty
Summary
A deficiency was identified when a resident with a history of anxiety and receiving regular dialysis treatments did not consistently receive Ativan (Lorazepam) as ordered. Medical record review showed that the resident was prescribed Ativan 0.5 mg at bedtime and a combination of 1.0 mg and 0.5 mg prior to dialysis sessions. However, documentation on drug control sheets failed to confirm that the evening dose of Ativan was removed from the supply on seven specific dates, despite staff recording its administration on the medication administration record (MAR). Additionally, on three occasions, a 1.0 mg dose was removed and presumably administered instead of the ordered 0.5 mg dose, indicating the resident may have received double the intended dose on those evenings. Further review revealed that duplicate orders for Ativan 0.5 mg to be given with 1.0 mg on dialysis days resulted in staff documenting administration of two 0.5 mg tablets and one 1.0 mg tablet on certain mornings, leading to a total of 2.0 mg being given instead of the ordered 1.5 mg. The discrepancies between the MAR and the drug control sheets, as well as the lack of documentation for medication removal, indicate failures in both medication administration and controlled substance documentation for this resident.
Failure to Accurately Document Medication Administration and Resident Care Activities
Penalty
Summary
Staff failed to accurately document medication administration and care activities for multiple residents. For one resident with an order for Ativan (Lorazepam), a controlled substance, the medication administration record showed consistent documentation of administration, but the corresponding controlled drug sheets lacked entries for seven specific dates, indicating no documentation that the medication was removed from supply on those occasions. Despite requests, no additional documentation was provided to account for these discrepancies. In another case, a resident with severe dysphagia and a care plan requiring supervision and assistance during meals was observed feeding themselves unsupervised in bed. The care plan specified that the resident should be out of bed for meals and that any refusals should be documented. However, staff documented that the resident was out of bed for breakfast, contrary to direct observation, and failed to record the resident's refusal to get out of bed. Additionally, documentation for activities of daily living (ADL) was incomplete for several residents. One resident's records had blank spaces for personal hygiene care and repositioning tasks across multiple shifts. Another resident, dependent on staff for total care, reported not receiving a shower for at least two weeks, and observations confirmed poor hygiene. The medical record indicated a shower was given, but the resident denied this, and no supporting shower sheet was found. The DON confirmed the lack of accurate documentation for these care activities.
Infection Control Lapses in Hand Hygiene, Barrier Precautions, and Laundry Handling
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices among staff. In one instance, a nurse was observed preparing and administering medications to a resident, washing the resident's feet, and applying medicated cream without performing hand hygiene between glove changes. The nurse also removed unused gloves from the clean supply, handled them with unwashed hands, and returned them to the box, further breaching infection control protocols. The nurse only performed hand hygiene after handling dirty laundry, not between other critical steps as required. The unit nurse manager confirmed that staff are expected to perform hand hygiene between glove changes, which was not followed in this case. Another deficiency was observed with a geriatric nurse aide providing morning care to a resident on Enhanced Barrier Precautions (EBP) due to a wound and dialysis access. The aide wore gloves but failed to wear a gown during high-contact care activities, despite signage and policy requiring both gloves and gowns for such residents. The aide acknowledged removing the gown after it became wet and continuing care without replacing it. Additionally, the facility's laundry practices were found deficient, with soiled linen bins lacking lids and proper labeling, and clean laundry bins being brought into the soiled area without clear separation. Staff reported that bins have never had lids and are only cleaned biweekly, and the Director of Environmental Services confirmed the ongoing issue with uncovered soiled linens.
Failure to Thoroughly Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents. In one case, a resident reported being struck by a staff member during feeding, resulting in visible redness and pain near the eye. The facility's documentation lacked timely and complete follow-up, including missing a required follow-up change in condition form and failing to ask the resident about the injury. The Director of Nursing confirmed that the necessary follow-up was not completed, and no additional information was provided to address the lack of a thorough investigation. Another incident involved a resident who was reported by a hospital emergency department to have been pushed, resulting in significant bruising and bleeding. The facility's investigation file contained incomplete and improperly identified medical records, lacked any witness or staff interviews, and did not include a review of the resident's facility medical records. The Nursing Home Administrator acknowledged the absence of a proper investigation and could not provide further evidence to support the facility's response to the allegation. Additional deficiencies were found in the investigation of an allegation of inappropriate touching and an incident where a resident with a history of stroke and hemiplegia reported rough handling by staff. In both cases, the facility's investigation documentation was incomplete, with missing or undated interview records, unclear identification of involved staff, and inconsistencies in the reporting of events. The investigations failed to identify alleged perpetrators, lacked supporting documentation such as police reports, and did not reconcile clinical findings with the reported allegations. These failures resulted in incomplete and insufficient investigations into serious allegations of abuse.
Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to dependent residents, as evidenced by multiple instances of missed or insufficient care. Several residents who were incontinent or required total assistance did not consistently receive timely incontinence care, bathing, or grooming. For example, one resident was observed with a soaked bedsheet and urine odor, and documentation showed that incontinent care was not recorded for all shifts on over half of the days reviewed. The DON confirmed the lack of documentation for this resident's care. Another resident, who required staff assistance for showers and had a care plan specifying two showers per week, received only three showers over a month, with missed opportunities to re-offer showers after refusals, particularly on dialysis days. In another case, a resident fully dependent on staff for eating had 15 shifts with no documentation of assistance and three shifts with only set-up, despite being unable to feed themselves. The DON acknowledged that documentation should have indicated when family provided care, but this was not consistently done. Additional deficiencies included residents with hemiplegia and high cognitive function scores who reported not receiving bed baths, changes, or showers as scheduled, despite being fully dependent on staff. Documentation sometimes indicated care was provided when residents denied receiving it, and required supporting documentation, such as shower sheets, was missing. Staff interviews revealed that care was sometimes delayed or omitted, with some staff waiting for residents to request assistance rather than proactively providing scheduled care.
Failure to Maintain Safe Operating Condition of Hoyer Lift
Penalty
Summary
A deficiency was identified when the facility failed to maintain the safe operating condition of patient care equipment, specifically a Hoyer lift used for resident mobility assistance. Record review of the grievance log revealed that a grievance was filed by a social service designee and investigated by a registered nurse, who confirmed that one of two facility Hoyer lifts was not in safe operating condition due to dead batteries. Interviews with the complainant and the county ombudsman validated the grievance, and it was confirmed that the director of nursing and the nursing home administrator were aware of the issue. No harm was reported to the resident involved.
Failure to Safeguard Resident's Personal Food Due to Inconsistent Policy Implementation
Penalty
Summary
The facility failed to ensure the safety and availability of a resident's personal property, specifically food brought in by family members. A long-term resident reported difficulty chewing facility-provided food, leading their family to bring in outside food. The family later discovered that the food they had brought was missing from the unit's refreshment refrigerator. Review of the facility's 'Food from Home Policy' indicated that all food items brought in by families must be labeled with content and date, and are to be discarded if not consumed within three days. Interviews with staff revealed inconsistencies in the application of this policy. The kitchen staff reported discarding any items without an expiration date, while nursing staff stated that only the date the food was placed in the refrigerator was required, not an expiration date. This discrepancy led to the removal of food items that may have been within the allowed timeframe, resulting in the resident's food being discarded and unavailable. The concern regarding inconsistent policy implementation was discussed with facility leadership, but no further information was provided before the survey concluded.
Failure to Ensure Resident Access to Call Bell and Lighting Controls
Penalty
Summary
Surveyors determined that the facility failed to provide reasonable accommodations to maintain residents' independence by not ensuring access to call lights and lighting controls. Specifically, one resident was observed on two separate occasions seated in a wheelchair at the bedside with the call bell tied to the left side bed rail, making it inaccessible to the resident. On both occasions, staff members confirmed that the call bell was out of reach and repositioned it closer to the resident only after being prompted by the surveyor. Additionally, the issue of inaccessible lighting controls was noted in all rooms observed, though the report focuses on the repeated failure to ensure the call bell was within reach for the resident in question. The Nursing Home Administrator confirmed that the expectation is for the call bell to be accessible to residents at all times, but the deficiency was observed multiple times during the survey period.
Failure to Ensure Proper Discussion and Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's health care advance directives were properly discussed and documented. A review of the medical record for a resident with adequate decision-making capacity showed that staff had documented the presence of an advance directive during admission and in a subsequent social service assessment. However, upon further review, no advance directive was found in either the electronic medical record or the paper chart. Instead, only a durable power of attorney document, which did not address health care decisions, was located in the record. Interviews with the Social Service Designee (SSD) revealed that there was confusion regarding the correct documentation, and the SSD acknowledged that the document on file was not related to health care. There was also no documentation indicating that the family was informed about the missing or incorrect paperwork. The deficiency was identified when surveyors noted the discrepancy between the documentation stating an advance directive was on file and the actual absence of such a document in the resident's records.
Failure to Maintain Cleanliness and Timely Linen Changes for Residents
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. One resident's room was found to have dark debris, dried food particles, and dried sticky fluid on the floor, which had reportedly been present for at least two weeks. Both a housekeeping technician and the director of environmental services confirmed the room's unclean condition and acknowledged that resident rooms were supposed to be cleaned daily, but this had not occurred. Another resident, who is dependent on staff for total care due to a history of stroke and has a BIMS score of 15, reported that their bed linens were not changed regularly, typically only every couple of weeks. Over several days, surveyors observed the resident's bed linens to be visibly stained, soiled, and containing skin debris, food particles, and a urine-soaked incontinence pad. Despite the facility's policy to change linens on shower days and when soiled, the resident's sheets remained unchanged for several days, as confirmed by both the resident and staff interviews.
Failure to Initiate Grievance Process for Missing Resident Property
Penalty
Summary
The facility failed to implement its grievance policy when a resident reported missing personal property. Upon admission, the resident brought a wheelchair with leg rests, which were later reported missing for approximately one month. The resident informed the physical therapist, who attempted to locate the missing leg rests and provided alternative leg rests in the meantime. Interviews with staff revealed that although the concern was known to both the physical therapist and a unit nurse, there was no written documentation or formal initiation of the grievance process regarding the missing property. Further interviews confirmed that the standard procedure for missing property was to initiate the grievance process by the first staff member made aware of the issue. The Director of Rehabilitation acknowledged that this process was not followed in the case of the missing wheelchair leg rests. As a result, the facility did not make prompt efforts to resolve the resident's grievance in accordance with its established policy.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required regulatory time frame for one resident. Specifically, the admission MDS assessment, which is mandated to be completed by the end of day 14 following admission, was not finalized until day 18, resulting in a four-day delay. This was confirmed through record review and staff interviews, with the MDS Coordinator acknowledging the late completion. The deficiency was identified during a review of residents assessed for accidents, and the late assessment led to a lapse in maintaining current and accurate assessment records necessary for appropriate care planning.
Failure to Hold Interdisciplinary Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to ensure that interdisciplinary care plan meetings were held following Minimum Data Set (MDS) assessments for a resident reviewed for unnecessary medications. Medical record review showed that the resident had a quarterly MDS assessment completed in March and a significant change MDS assessment completed in May. However, there was no documentation indicating that care plan meetings were scheduled or conducted after either assessment. When the surveyor requested records of care plan meetings since January, the Director of Nursing confirmed that no such meetings had occurred for this resident during that period. This deficiency was identified through medical record review and staff interviews, which confirmed the absence of required interdisciplinary care plan meetings following the completion of MDS assessments.
Failure to Implement and Document Accident Prevention Interventions
Penalty
Summary
The facility failed to implement and document care plan interventions designed to prevent accidents for three residents identified as being at risk. For two residents with a history of falls, both had physician orders and care plans requiring the use of low beds with bilateral floor mats. However, during multiple observations, these fall mats were not present, despite staff having documented on the Treatment Administration Record (TAR) that the interventions were in place. The absence of the mats was confirmed by the unit nurse manager, and there was no indication that the mats had been removed for care or other reasons during the observed periods. For a third resident assessed as being at risk for elopement, the care plan and orders required the use of a wander guard bracelet and a check of its functionality every shift. While the resident was observed wearing the bracelet and staff documented its placement, there was no documentation of functionality checks after the order for this was discontinued. The unit nurse manager confirmed that both placement and functionality checks should be documented, but only placement was being recorded. These failures demonstrate that the facility did not ensure that care plan interventions to prevent accidents were consistently implemented or documented as required.
Failure to Provide Physician-Ordered Pain Management and Documentation
Penalty
Summary
The facility failed to provide appropriate pain management services as ordered by physicians for two residents. In the first case, a resident with an order for PRN oxycodone for severe pain reported experiencing severe pain and waiting several hours for medication, only to be told by nursing staff that the medication was unavailable. Review of medication records and the narcotic sign-out sheet confirmed that the last dose had been administered earlier that morning and that no further medication was available in the facility at the time of the resident's request. In the second case, a resident with chronic pain had physician orders requiring non-pharmacological interventions (NPIs) to be attempted prior to administering PRN pain medication. Review of the medical record and medication administration records revealed that there was no documentation of pain assessments or attempts at NPIs before administering the PRN pain medication on several occasions. The lack of documentation included missing information on pain location, type, and whether NPIs were attempted prior to medication administration.
Failure to Provide Necessary Behavioral Health Services and Medication Administration
Penalty
Summary
The facility failed to ensure that necessary behavioral health care and services were provided to a resident with a documented history of anxiety disorder, insomnia, and moderate depression. The resident had been assessed using the Minimum Data Set (MDS), which indicated moderate depression, and was noted by staff to have anxiety issues. The psychiatric nurse practitioner evaluated the resident and prescribed Ativan and Melatonin, with a recommendation for continued behavioral health services. However, review of the controlled drug sheets revealed that the evening dose of Ativan was not documented as removed from the supply on seven occasions in June, despite the resident expressing uncertainty about receiving the medication as ordered. No additional documentation was provided to confirm administration of the medication on those dates. Further review of the medical record showed that a psychologist had seen the resident and recommended follow-up psychotherapy within 2-3 weeks, stating that the resident's condition would deteriorate without continued treatment. Despite this, there was no documentation of any follow-up behavioral health visits by the psychologist, psychiatric nurse practitioner, or other behavioral health providers after the initial session. The absence of both medication administration documentation and timely behavioral health follow-up constituted a failure to provide necessary behavioral health care and services as required.
Pharmacist Failed to Identify Medication Errors Due to Incomplete Record Review
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a thorough monthly drug regimen review by not reviewing sufficient sections of a resident's medical record to identify significant medication errors. For one resident receiving behavioral health services, there were documented errors involving the administration of Ativan, including missed evening doses on seven occasions and the administration of an extra 0.5 mg dose on five occasions during the month reviewed. These discrepancies were identified through a review of both the drug control sheets, which were kept in a bound book on medication carts and not included in the electronic health record, and the Medication Administration Record (MAR). Further review revealed that there were duplicate active orders for Ativan, leading to confusion and incorrect dosing, with staff administering a total of 2.0 mg instead of the ordered 1.5 mg on certain days. The pharmacist responsible for the monthly medication regimen review completed the review remotely and did not identify these errors, as she relied on the recap summary and MAR, which she believed to be identical, and did not compare them with the drug control sheets. The pharmacist confirmed that the duplicate order did not appear on the summary she reviewed and acknowledged that she was not in the building to check the drug control sheets at the time of the review.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an incident of alleged abuse involving a resident with severely impaired mental cognition was thoroughly investigated and reported to the state agency in a timely manner. A family member of the resident reported to a nurse that another resident may have been inappropriately touching the resident. The nurse documented and signed a statement regarding the allegation, but there was a two-day delay before the Director of Nursing submitted the initial report to the state agency. The Director of Nursing acknowledged this delay during an interview, despite stating that the concern was investigated and reported immediately.
Failure to Provide Consistent Negative Pressure Wound Therapy and Documentation
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for a resident with a diabetic foot wound requiring Negative Pressure Therapy (VAC). The resident had a history of Type 2 Diabetes Mellitus with a foot ulcer, recent surgical amputation, and other significant medical conditions. Physician orders required continuous VAC therapy to the right foot, with nursing staff responsible for assessing and documenting the VAC's functioning every shift. However, documentation was missing for several consecutive days, and there was no evidence that the VAC was assessed or functioning properly during this period. Progress notes and the Treatment Administration Record lacked entries confirming the required care was provided on multiple days. Interviews with nursing staff, the wound specialist, and the Director of Nursing confirmed that the VAC was not consistently monitored or documented, and that the wound care provided over the weekend was substandard. The wound specialist noted that the VAC appeared to have not been working for several days prior to her assessment, and the resident's surgical site deteriorated as a result. The DON acknowledged that the lack of documentation indicated a failure to provide care in accordance with professional standards, as required for wound healing and prevention of further complications.
Latest citations in Maryland
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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