Dennett Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, Maryland.
- Location
- 1113 Mary Drive, Oakland, Maryland 21550
- CMS Provider Number
- 215216
- Inspections on file
- 15
- Latest survey
- October 10, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Dennett Rehab Center during CMS and state inspections, most recent first.
A resident with cerebral palsy and intellectual disabilities was subjected to verbal abuse by a GNA, who expressed frustration and made derogatory comments about the resident's behavior. This occurred in the presence of other staff and a cognitively intact resident. Despite having received training on abuse, the GNA failed to provide appropriate care, leading to a deficiency finding during a complaint survey.
A facility failed to secure residents' medications, leading to misappropriation by an LPN. Narcotic discrepancies were noted, and a family reported a medication mix-up. The facility's investigation linked the issues to the LPN, who forged signatures and was associated with missing narcotics. The LPN was terminated after the discrepancies were discovered.
Facility staff failed to follow infection control guidelines by not wearing the required PPE, including gowns, while providing care to a resident with a gastrostomy tube. The resident was uncooperative, and the staff, including an LPN and two GNAs, did not adhere to the Enhanced Barrier Precaution sign instructions, leading to a deficiency noted by a surveyor.
Two residents at risk for elopement left the facility unsupervised due to unsecured exit doors. One resident was found in the parking lot after exiting through an employee entrance without locks or alarms. Another resident, with a history of wandering, left through an improperly latched door and was found in the woods. The facility's failure to secure exits and supervise residents led to these incidents.
The facility was found to have insufficient nursing staff, with GNAs caring for 20 to 27 residents per shift, leading to delays in care and missed showers. Staff interviews revealed consistent understaffing, and the facility's staffing levels did not meet the state minimum standard of 3.0 PPD. Residents' ADLs documentation showed incomplete or missed showers, highlighting the inadequacy of care provided.
The facility failed to employ a full-time RD or qualified DM, affecting all 75 residents. The previous DM left in early November 2024, and the RD worked remotely without being onsite. The facility was attempting to hire a new DM, but no viable candidates had applied, leaving the Dining Services department without necessary guidance and oversight.
The facility failed to provide sufficient competent dietary staff, resulting in unsanitary kitchen conditions and delayed meal service. Observations revealed unclean kitchen equipment and late meal deliveries to various dining areas. Residents reported meals were often served later than scheduled, and a shortage of the main entree caused further delays. The Dietary District Manager acknowledged the need for proper staff training.
The facility failed to properly store and label food, maintain cleanliness of kitchen equipment and walls, and ensure food served to residents was covered and at appropriate temperatures. Observations revealed undated and uncovered food items, unclean kitchen equipment, and uncovered cookies on meal trays. Pudding was served at an elevated temperature, and the Dietary District Manager confirmed these deficiencies.
The facility failed to ensure a dignified dining experience by serving meals on disposable plates and not serving meals simultaneously to residents at the same table. Observations showed residents received cookies on paper plates despite available dishware, and some residents waited for meals while others at the same table were already eating. Staff acknowledged these practices as dignity issues.
The facility failed to provide palatable meals, as observed during a survey. Residents reported that food was often cold and lacked seasoning. A test tray review confirmed that meals were not prepared according to recipes, resulting in dry and bland dishes. The Dietary District Manager acknowledged that the chicken pot pie was too thick and dry due to not following the recipe, and the Visiting Dietary Manager confirmed that the country style tomatoes and mashed potatoes were not properly seasoned.
The facility failed to honor the preferences of two residents. One resident's bed and chair were moved against their wishes, disrupting their accustomed room setup. Another resident, at risk for falls, was unable to reach the call bell to request bathroom assistance, contrary to their care plan. These actions demonstrate a lack of consideration for resident needs and preferences.
Two residents in the facility were subjected to verbal abuse by staff members. One resident, with a history of stroke and depression, was verbally abused by a GNA, who used expletive language. Another resident with Alzheimer's disease was verbally abused by a staff member, as witnessed by a visitor. The facility confirmed both incidents, indicating a failure to protect residents from verbal abuse.
The facility failed to report an allegation of verbal abuse within the required 2-hour timeframe to the Office of Health Care Quality. A GNA was overheard cussing verbally at a resident, but the report was not sent until the following day, as evidenced by a failed fax confirmation sheet. The NHA and Regional Director confirmed the findings and were not employed at the time of the incident.
A facility failed to thoroughly investigate an alleged verbal abuse incident involving a resident. An LPN and a GNA overheard another GNA cussing at a resident. The investigation was incomplete, lacking additional staff or resident interviews. The NHA and Regional Director confirmed the lack of documentation and were not employed at the time of the incident.
A resident with COPD and chronic respiratory failure experienced a delay in receiving prescribed respiratory inhalers due to flagged allergy concerns. An LPN messaged the Medical Director, but a response was delayed as the Director was initially unavailable. A family member's inquiry led another LPN to contact the Medical Director directly, resulting in an order for Albuterol nebulizer treatments, which the resident found helpful. The facility's Administrator and DON confirmed the delay in medication administration.
A resident with dementia experienced significant weight loss, dropping from 110 to 99 pounds over several months. The facility staff failed to intervene promptly, with delayed assessments and minimal dietary recommendations. The current dietitian acknowledged the need for timely reweighing and interventions such as fortified foods and snacks.
A resident admitted with chronic pain did not receive timely pain medication due to a delay in clarifying physician orders. An LPN attempted to contact the Medical Director without success, resulting in the resident not receiving medication until the next shift. The resident's pain level remained moderately strong, and no further medication was given before their transfer.
A resident's MDS discharge assessment was inaccurately coded as a discharge to a hospital instead of an assisted living facility. The MDS Coordinator acknowledged the error, which was contrary to the RAI manual guidelines. The Social Services Director confirmed the correct discharge location, highlighting a lapse in accurate documentation.
A facility failed to implement a pressure ulcer care plan for a resident with a stage two ulcer on the left heel. The care plan required treatment and floating of heels, but these were not documented or communicated effectively, leading to non-compliance with physician's orders. Despite this, the ulcer showed improvement. The oversight was due to incorrect entry in the EMR, as confirmed by staff interviews.
A facility failed to store oxygen tubing and nasal cannula in a clean manner for a resident with COPD, as the equipment was found unbagged on the floor. The facility's policy did not address proper storage, and a nurse confirmed the tubing should be bagged when not in use.
The facility failed to follow infection control guidelines, including improper PPE use for residents on isolation and inadequate wound care procedures. Additionally, the Legionella Water Management Program policy had not been reviewed annually as required.
A baseboard heater cover in the East Wing was found to be sharp and protruding, posing a potential injury risk. A resident, who was cognitively intact, was in proximity to the hazard. The Maintenance Director was unaware of this specific issue but noted that all heaters had damage due to cart collisions. Previous requests for new covers were denied, and the Administrator was unaware of any injuries. Preventive maintenance checks had been conducted, but the problem remained.
The facility failed to submit required staffing data to CMS for the third quarter of 2024 by the deadline. The policy requires data to be reported quarterly through the PBJ system, but the facility missed the August 14 deadline. The Administrator was unaware of the missed submission, as the Regional Office handles reporting, leading to a noted deficiency.
Verbal Abuse of a Vulnerable Resident by Staff
Penalty
Summary
The facility failed to protect a vulnerable resident from verbal abuse, as observed during a complaint survey. Resident #39, who has cerebral palsy and unspecified intellectual disabilities, was seen repeatedly scooting on the floor or moving in a wheelchair throughout the day. During one such instance, a Geriatric Nursing Assistant (GNA #5) expressed frustration verbally in the presence of Resident #39 and another resident. GNA #5 made derogatory comments about Resident #39's behavior, suggesting that the resident should be confined to an office to prevent further disruption. This interaction was witnessed by other staff members, including a Licensed Practical Nurse (LPN) and another GNA. The incident was reported to the Director of Nursing (DON) and the Nursing Home Administrator (NHA) immediately. A review of Resident #39's medical records confirmed the resident's non-verbal status and intellectual disabilities. Additionally, GNA #5's employee file indicated that he had received annual in-service training on abuse, yet failed to apply this training appropriately in his interactions with Resident #39. The facility's inability to ensure respectful and appropriate care for Resident #39, as evidenced by GNA #5's actions, was discussed with the facility during the survey exit.
Medication Misappropriation and Documentation Issues
Penalty
Summary
The facility failed to ensure the security and proper maintenance of residents' medications, leading to misappropriation. This deficiency was identified through a review of facility-reported incidents, medical records, and staff interviews. Specifically, narcotic discrepancies and misappropriation were noted for two residents. A family reported that a sedative medication brought from home was replaced with a diabetic medication after the resident was discharged. The facility's investigation could not confirm a mix-up but identified a pattern of incorrect documentation, missing forms, and false documentation linked to a specific nurse, LPN #14. This nurse was found to have forged signatures and was associated with the disappearance of narcotic medications from two residents. The facility's investigation revealed that Tramadol and Gabapentin were taken from the residents. The discrepancies were primarily noted on days when LPN #14 worked, and the pharmacy sheets did not match. The DON and ADON discovered a questionable signature on a narcotic log, which led to further scrutiny and the eventual termination of LPN #14. The facility's failure to secure medications and prevent misappropriation resulted in a deficiency citation for past non-compliance.
Inadequate PPE Usage During Resident Care
Penalty
Summary
The facility failed to adhere to infection control and prevention guidelines when staff did not don the required personal protective equipment (PPE) before entering a resident's room and providing hands-on care. During a surveyor's observation, an LPN and two GNAs were seen interacting with a resident who required nutrition administration via a gastrostomy tube. The resident was uncooperative, and the staff members were attempting to manage the situation without wearing the appropriate PPE, which included gowns as indicated by the Enhanced Barrier Precaution sign on the resident's door. The incident involved a resident who was active and unresponsive to the LPN's requests during the administration of a fluid bolus. The staff's failure to wear the necessary PPE, despite being aware of the resident's potential behavioral challenges, was noted by the surveyor. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of these observations during the survey and again at the exit meeting.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent two residents, who were assessed to be at risk for elopement, from leaving the premises unsupervised. In the first incident, a resident was found in the facility parking lot sitting in a truck after eloping through an employee entrance that was not secured with a lock or alarm. The resident's wheelchair was found in the hallway, indicating the path taken to exit the building. The lack of security measures on the employee doors allowed the resident to leave the facility unnoticed. In the second incident, another resident eloped from the facility and was later found in the woods by the police. This resident had a history of wandering and was wearing a wanderguard for safety. However, the exit door on the 700 unit was not properly latched after a delivery, which allowed the resident to leave the building. The alarm system did not activate because the door was not shut properly, highlighting a failure in the facility's security protocol. Both incidents demonstrate a significant lapse in the facility's ability to secure exit points and adequately supervise residents at risk for elopement. The facility's failure to ensure that all exit doors were properly secured and monitored contributed to these elopements, posing an immediate jeopardy to the safety of the residents involved.
Removal Plan
- Head count for all residents
- Placed alarms on all exit doors
- Reassessed all residents at risk for elopement
- Staff educated on elopement assessment and prevention
- Incident included in the facility's QAPI plan
- All facility entry and exit ways and windows checked for security, penetration and proper function
- Facility elopement binders checked for accurateness and in use wanderguards checked for function
- Maintenance educated on daily checks of entry and exit door ways for security, penetration and proper function
Insufficient Staffing Leads to Inadequate Resident Care
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of its residents, as evidenced by nine out of twenty-one complaints reviewed by the Office of Health Care Quality (OHCQ). These complaints highlighted that geriatric nursing assistants (GNAs) were responsible for caring for 20 to 27 residents per shift, leading to delays in care, missed showers, and inadequate toileting. The Resident Census and Conditions CMS 672 form indicated that all 75 residents required assistance with daily activities, yet the facility's staffing levels were inadequate to meet these needs. Interviews with staff members revealed consistent understaffing issues, with GNAs and nurses frequently working short-staffed. GNAs reported being unable to complete necessary rounds and provide showers due to the high number of residents assigned to them. The facility's use of agency staff and a bonus program were mentioned as attempts to address staffing shortages, but these measures were insufficient to meet the state minimum standard of 3.0 PPD (per patient per day hours). The facility's actual worked nursing schedules for July and August 2024 showed that the state minimum was not met for the majority of days reviewed. The deficiency was further evidenced by the review of residents' activities of daily living (ADLs) documentation, which showed incomplete or missed showers and bed baths. Specific residents were noted to have received fewer showers than scheduled, with documentation often marked as partial or not applicable. The facility's assessment documented a range of resident needs, including medical management, behavioral symptoms, and reduced physical functioning, yet the staffing levels were inadequate to provide the necessary care. The Nursing Home Administrator and Director of Nursing were informed of these staffing concerns during the survey.
Deficiency in Food and Nutrition Services Staffing
Penalty
Summary
The facility failed to employ a full-time Registered Dietitian (RD) or a qualified Dietary Manager (DM) to oversee the food and nutrition services, which had the potential to affect all 75 residents. The facility's policy required the employment of sufficient staff with appropriate competencies and skill sets, including a qualified dietitian or other clinically qualified nutrition professional, either full-time or part-time. If not employed full-time, a director of food and nutrition services meeting specific qualifications should be employed. However, the facility did not have a DM since the previous manager's departure in early November 2024, and the RD worked remotely without being onsite since the DM left. Interviews with the Dietary District Manager (DDM) and the Administrator confirmed the vacancy of the DM position and the remote status of the RD. The DDM stated that the facility was in the process of hiring a new DM, but no viable candidates had applied. The Administrator reiterated the vacancy and the ongoing efforts to fill the position, highlighting the absence of a qualified individual to provide necessary guidance and oversight to the Dining Services department, as required by the facility's policy.
Deficiency in Dietary Staff Competency and Meal Timeliness
Penalty
Summary
The facility failed to provide sufficient competent dietary staff to ensure meals were prepared in a sanitary environment and served on time. During an inspection, the kitchen was found to be unclean, with food preparation and service equipment such as the mixer, convection oven, and grill spill pan having visible food debris or spilled liquids. Additionally, opened and leftover food was not labeled, dated, or covered when stored. The Dietary District Manager acknowledged that while cleaning schedules were available, staff were not completing them, and many staff members had been employed for less than six months and required proper training. The facility also failed to serve meals on time as scheduled. Observations revealed that resident evening meals were consistently delivered later than scheduled to various dining areas, including the main dining room and the Far East and East units. Interviews with Geriatric Nurse Aides confirmed the delays, and residents reported that meals, particularly lunch and evening meals, were often served later than scheduled. The Dietary District Manager confirmed the delays, and the facility administrator expressed an expectation for meals to be served on time. Specific incidents included running out of the main entree, Rancher's Chicken Thighs, during meal preparation, which caused further delays in meal service. The Visiting Dietary Manager noted that staff had production sheets to guide food preparation, but an error in using too many chicken thighs for pureed meat led to a shortage. This resulted in a delay in serving the last resident on the East unit, with meals being delivered 29 minutes later than scheduled.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to its food storage and preparation policies, as observed during a kitchen inspection. Several food items in the walk-in refrigerator and freezer were found undated, uncovered, or improperly stored, including bowls of fruit cocktail, pans of pudding, and a bag of parmesan cheese. Additionally, a scoop was improperly stored in a bin of flour, with its handle embedded in the flour. The Dietary District Manager (DDM) confirmed these observations, acknowledging that food should be covered, labeled, and dated, and that the scoop should not be stored in the flour bin. The cleanliness of the kitchen equipment and walls was also found lacking. The kitchen's mixer, grill top, convection oven, and reach-in refrigerator were observed with accumulations of food spills and debris. The wall next to the stove top was unclean with dried food splatters. The DDM confirmed these cleanliness issues, stating that equipment should be cleaned according to the kitchen's schedule or as needed, and that the wall should be kept clean by staff. Furthermore, during meal service, residents were served uncovered cookies on their meal trays, which were delivered from enclosed food carts to resident rooms. The DDM and the Administrator both stated that food on resident meal trays should be covered. Additionally, pudding served from the kitchen's tray line was found to be at an elevated temperature of 52.2 degrees Fahrenheit, above the required 41 degrees Fahrenheit or below. The Dietary Aide responsible for preparing the pudding did not monitor its temperature before serving, and the DDM confirmed that staff should have ensured the pudding was at the correct temperature before service.
Dignity Issues in Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for residents by serving meals on disposable plates and not serving meals simultaneously to residents seated at the same table. Observations revealed that residents on four hallways were served cookies on paper plates, despite the kitchen's dish machine being functional and regular dishware being available. The Dietary District Manager acknowledged that disposable products should only be used when the dish machine is not working or in emergencies, indicating a lapse in staff training and adherence to the facility's policy on dignity. Additionally, in the Far East dining room, residents seated at the same table received their meals at different times, causing some residents to wait while others were already eating. This was observed with several residents, who expressed dissatisfaction with the delay. The Assistant Director of Nursing and the Business Office Manager both recognized this as a dignity issue, as residents should not have to wait for their meals while others at the same table are served. The Administrator confirmed the expectation that meal trays should be delivered in sequence to avoid such situations.
Failure to Ensure Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to serve palatable food to residents, as observed during a survey. On one occasion, residents on a dysphagia advanced diet were served a scoop of dry, unidentifiable food, later identified as ground meat chicken pot pie. The Dietary District Manager (DDM) confirmed that the chicken pot pie was too thick and dry because the cook did not follow the recipe, which required moistening the dish with gravy or broth. This failure to adhere to the recipe resulted in unappetizing meals for residents. Two residents, identified as R16 and R59, expressed dissatisfaction with the meals served at the facility. R16, who was cognitively intact, reported that the food was often cold and unpalatable, with the quality varying depending on the cook. R59, also cognitively intact, stated that the food lacked seasoning and could be improved. These complaints were consistent with the findings from the test tray review conducted by the surveyors. During the test tray review, the surveyors found that the food served was not prepared according to the facility's recipes. The country style tomatoes tasted bitter, and the mashed potatoes were bland and lacked seasoning. The Visiting Dietary Manager (VDM) confirmed these findings and noted that the country style tomatoes were not prepared with sugar or flour as required by the recipe. The mashed potatoes were made with only water and margarine, as per the recipe, but still lacked flavor. These observations highlighted the facility's failure to ensure food quality and palatability as per their policy.
Failure to Honor Resident Preferences and Ensure Call Bell Accessibility
Penalty
Summary
The facility staff failed to honor the needs and preferences of two residents during an annual/complaint survey. For Resident #205, the facility moved the resident's bed and chair against the wishes of the resident and their representative. The resident had been accustomed to having the bed against the wall and the chair positioned to look out the window. Despite multiple requests from the resident's representative to revert the furniture to its original position, the facility did not comply for approximately one month. The decision to move the furniture was part of a trial initiated by the facility, but the resident and their representative were not involved in the decision-making process. For Resident #1, the facility failed to ensure the call bell was within reach, as required by the resident's care plan. The resident, who is at risk for falls due to paraplegia and cognitive deficits, was observed holding their private area and stating the need to use the bathroom. The call bell was found on the floor, out of the resident's reach, contrary to the care plan's intervention to maintain the call light within reach. A geriatric nursing assistant confirmed that the call bell should have been accessible to the resident when in the wheelchair.
Verbal Abuse of Residents by Facility Staff
Penalty
Summary
The facility staff failed to protect residents from verbal abuse, as evidenced by two incidents involving different residents. In the first incident, a resident with a history of cerebral infarction, chronic obstructive pulmonary disease, and depression was verbally abused by a geriatric nursing assistant (GNA). The GNA was overheard by other staff members using expletive language towards the resident, indicating a failure to maintain a respectful and abuse-free environment. The incident was documented, and the GNA involved was identified and suspended. In the second incident, a resident with Alzheimer's disease was verbally abused by a staff member, as witnessed by a visitor. The staff member was reported to have used harsh and inappropriate language towards the resident, who was unable to recall the incident due to poor cognition. The facility's investigation confirmed the verbal abuse, and the staff member was reported to the Board of Nursing. These incidents highlight a failure in the facility's duty to protect residents from verbal abuse by staff members.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required 2-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). This deficiency was identified during a review of facility-reported incidents, specifically involving an incident where a geriatric nursing assistant was overheard cussing verbally at a resident. The incident occurred on 1/2/22, but the report was not sent until 1/3/22, as evidenced by a failed fax confirmation sheet and the date on the self-report form. There was no documentation of when the final 5-day report was sent to the state agency. The Nursing Home Administrator and the Regional Director of Clinical Operations confirmed the surveyor's findings and stated they were not employed at the facility at the time of the incident.
Incomplete Investigation of Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident of alleged verbal abuse involving a resident. On January 2, 2022, at 5:35 PM, an LPN and a geriatric nursing assistant (GNA) overheard another GNA verbally cussing at a resident as they exited the resident's room. The investigation into this incident, identified as MD00180784, was found to be incomplete during an annual and complaint survey. The investigative packet provided to the surveyor included written statements from the two staff members who overheard the incident, but there were no additional staff or resident interviews conducted to determine if the GNA in question had been verbally abusive to other residents or to gather more information about the incident. On November 19, 2024, the Nursing Home Administrator and the Regional Director of Clinical Operations confirmed to the surveyor that no further documentation was available and acknowledged that the investigation was incomplete. They also noted that they were not employed at the facility at the time of the incident.
Delay in Medication Administration Due to Allergy Concerns
Penalty
Summary
The facility staff failed to provide treatment and services in accordance with professional standards of practice for a resident admitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Upon admission, the resident was prescribed four different respiratory inhalers, which were flagged for potential allergies. The LPN on duty messaged the Medical Director regarding these allergy concerns. However, there was a delay in receiving a response from the Medical Director, as he was initially unavailable and did not see the message until later. The delay resulted in the resident not receiving the necessary medication in a timely manner. A family member inquired about the resident's medications, prompting another LPN to review the situation and contact the Medical Director directly. The Medical Director then ordered Albuterol nebulizer treatments every four hours, which the resident reported as helpful. The facility's Administrator and Director of Nursing confirmed the delay in clarifying the physician orders and administering an alternative medication.
Failure to Timely Address Resident's Weight Loss
Penalty
Summary
The facility staff failed to intervene in a timely manner for a resident with weight loss, identified as Resident #205, during an annual survey. The resident, who was admitted in October 2021 with a diagnosis of dementia, experienced a significant weight loss from 110 pounds on October 23, 2023, to 102 pounds on November 1, 2023. Despite this notable weight loss, the resident was not assessed by the former dietitian until November 13, 2023, 12 days later, and the only recommendation made was to re-weigh the resident. The re-weigh did not occur until December 1, 2023, when the resident's weight was documented as 103 pounds. The resident was not reassessed by the dietitian until December 22, 2023, with no new recommendations made at that time. The resident's weight continued to decline, reaching 99 pounds by February 2, 2024. The former dietitian recommended a snack order but did not suggest any supplements. During an interview, the current dietitian, who began her position in August 2024, acknowledged that the resident should have been reweighed and assessed more promptly after the initial weight loss. The dietitian indicated that interventions such as fortified foods and snacks should have been considered initially, followed by supplements if necessary. The Regional Director of Clinical Operations confirmed the facility's failure to intervene timely for the resident's weight loss.
Failure to Administer Timely Pain Medication
Penalty
Summary
The facility staff failed to administer pain medications to manage a resident's pain in a timely manner. Resident #203 was admitted to the facility with a diagnosis of chronic pain and had a physician order for Hydrocodone-Acetaminophen 10-325 mg to be administered every 4 hours as needed for pain. Upon admission, the resident expressed upset over not receiving pain medication. LPN #5, who was responsible for the resident at the time of admission, sent the medication orders to the pharmacy but was informed that clarification from the physician was needed. Despite attempts to contact the Medical Director, LPN #5 was unable to obtain the necessary clarification and did not administer the pain medication. LPN #6, who took over the shift, managed to contact the Medical Director and subsequently the pharmacy, which confirmed that the required medication was available in the Ebox. LPN #6 then administered the pain medication to the resident. However, the resident's pain level was documented as moderately strong the following morning, and no further pain medication was administered before the resident was transferred from the facility. The facility's Administrator and Director of Nursing confirmed the failure to administer the pain medication in a timely manner.
Inaccurate MDS Discharge Assessment Coding
Penalty
Summary
The facility failed to ensure an accurate coding of the Minimum Data Set (MDS) discharge assessment for one resident, identified as Resident 73. The deficiency was identified through a review of the resident's records and interviews with facility staff. The resident was discharged to an assisted living facility, as documented in the Nursing Progress Note. However, the MDS discharge assessment was incorrectly coded as a discharge to a short-term general hospital. This error was confirmed by the MDS Coordinator, who acknowledged the mistake and stated that the coding should have reflected a discharge to home/community, as per the Resident Assessment Instrument (RAI) User Manual guidelines. Interviews with the facility's MDS Coordinator and Administrator revealed that the MDS Coordinator was responsible for coding the MDS assessments and was expected to follow the RAI manual. The Social Services Director also confirmed that the resident was discharged to an assisted living facility and that this information was communicated during Medicare Meetings. The incorrect coding of the discharge status was a result of the MDS Coordinator's oversight, despite having access to the correct information in the resident's progress notes and the RAI manual.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to implement a pressure injury intervention as per the physician's orders and care plan for a resident with a stage two pressure ulcer on the left heel. The resident, who was admitted with diagnoses including Alzheimer's disease, malnutrition, and osteoarthritis, had a care plan indicating the need for treatment to the left heel and to float the heels when in bed or a geriatric chair. However, the treatment was not documented as completed for several days, and the task of floating the heels was not included in the nurse aide care plan. Observations and interviews revealed that the resident was seen in a geriatric chair with heels resting on the footrest, contrary to the care plan's instructions. Registered nurses and geriatric nurse aides confirmed that the intervention to float the heels was not documented or communicated effectively, leading to the resident's heels not being floated as required. The Assistant Director of Nursing and the facility Administrator acknowledged the oversight, noting that the orders were not visible to the nurses due to incorrect entry in the electronic medical record. Despite the lack of documentation and implementation of the prescribed interventions, the resident's pressure ulcer showed signs of improvement. However, the failure to follow the care plan and physician's orders could have resulted in inadequate wound treatment and interventions for the resident. The facility's policies on wound care and comprehensive person-centered care plans were not adhered to, as evidenced by the lack of documentation and communication among the staff.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure that oxygen tubing and nasal cannula were stored in a clean and sanitary manner for a resident who required respiratory care. The facility's policy on oxygen administration did not address the proper storage of nasal cannula and tubing when not in use. During an observation, it was noted that the resident's oxygen tubing and nasal cannula were unbagged and lying on the floor next to the bed, which was confirmed by a registered nurse. The nurse acknowledged that the tubing should not be on the floor and should be placed in a bag when not in use. The resident involved was admitted with a diagnosis of chronic obstructive pulmonary disease and had a physician's order for oxygen administration at 3 liters per minute via nasal cannula due to respiratory failure with hypoxia. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Despite the resident's cognitive status, the improper storage of the oxygen equipment was observed, which could potentially lead to the equipment not being properly maintained.
Infection Control and Policy Review Deficiencies
Penalty
Summary
The facility failed to adhere to infection control and prevention guidelines, as evidenced by multiple observations and interviews. In one instance, a hospitality aide entered the room of a resident on droplet and contact precautions for COVID-19 without donning the required personal protective equipment (PPE). The resident had been diagnosed with paraplegia and asthma and was under strict isolation orders. Despite the presence of isolation signage and PPE supplies outside the room, the aide admitted to not wearing the necessary PPE, acknowledging the oversight during an interview. Another deficiency was observed during a wound care procedure for a resident with unspecified dementia. The licensed practical nurse (LPN) performing the procedure did not change gloves or wash hands after removing the old dressing and cleansing the wound. This failure to follow proper wound care protocol was acknowledged by the LPN, who admitted that the gloves should have been changed and hands washed to prevent infection. The infection preventionist and the administrator both confirmed the expectation for staff to adhere to infection control guidelines during such procedures. Additionally, the facility did not review its Legionella Water Management Program policy annually, as required. The policy had not been reviewed since 2018, and the maintenance director, who had been in the position for two years, could not recall any reviews being conducted. The administrator confirmed the lapse in policy review, noting it was scheduled for discussion at the next safety committee meeting.
Baseboard Heater Cover in Disrepair
Penalty
Summary
The facility failed to ensure that a baseboard heater cover was in good repair in the 100 Hall of the East Wing, which had the potential to cause injury to residents. Specifically, the metal cover of a baseboard heater outside the room of Resident 17 was observed to be sharp and protruding from the wall. Resident 17, who was cognitively intact with a BIMS score of 14 out of 15, was admitted to the facility on an unspecified date. The facility's policy titled 'Homelike Environment' emphasized providing a safe, clean, and comfortable environment for residents. The Maintenance Director, during an observation, acknowledged the issue and stated that he was unaware of the specific heater cover protrusion but had repaired many due to damage from carts. He mentioned that all baseboard heaters had damaged covers and that previous requests for new covers were denied by former facility owners. Despite daily preventive maintenance checks, the Administrator was not aware of any resident injuries related to the heaters. The Preventive Maintenance Checklist indicated that the heaters had been checked recently, but the issue persisted.
Failure to Submit Timely Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) for the third quarter of the federal fiscal year 2024. According to the facility's policy, staffing data should be reported electronically through the Payroll-Based Journal (PBJ) system in a uniform format specified by CMS. The policy mandates that staffing information is collected daily and reported quarterly, with a submission deadline of 45 days after the end of each fiscal quarter. For the third quarter, covering April 1 to June 30, the deadline was August 14. However, a review of the facility's PBJ report from CMS revealed that the data was not submitted within the required timeline. During an interview, the Administrator stated that they were unaware of the missed deadline for the PBJ report submission. The Administrator mentioned that the Regional Office is responsible for handling the reporting of this information, and they did not have a record of when the report was submitted. This lack of awareness and oversight led to the failure in meeting the CMS reporting requirements, resulting in a deficiency being noted during the survey.
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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