Denton Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Denton, Maryland.
- Location
- 420 Colonial Drive, Denton, Maryland 21629
- CMS Provider Number
- 215149
- Inspections on file
- 22
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Denton Nursing And Rehab during CMS and state inspections, most recent first.
A resident alleged that no staff provided care during an overnight (11p–7a) shift, and the facility’s follow-up investigation confirmed that the assigned GNA did not enter the room to provide care. Review of GNA task documentation for that shift showed no entries for bathing, bed mobility, oral hygiene, toileting, barrier cream after incontinence care, bowel and urinary incontinence care, or use of foam ankle boots in bed as tolerated. The DON stated that all care, including refusals, must be documented and that blank spaces indicate a lack of support that care was completed.
A resident reported to an Emergency Department that night-shift staff frequently left them sitting in urine and ignored call bells, prompting the resident to call 911. The ED note containing this neglect allegation was uploaded into the facility’s records, but the Administrator was unaware of the complaint and no investigation was identified. The DON stated the admitting nurse should have reviewed the hospital discharge paperwork and noted the complaint. In a separate facility-reported incident, the same resident alleged being left in soiled conditions for an extended period; however, only the initial report to the state was available, and the DON and Administrator could not locate the required investigation file or supporting documentation.
Surveyors identified that quarterly care plan meetings were not consistently held for a resident, with documented gaps where required meetings were missed despite the expectation for regular interdisciplinary review. In addition, a resident with documented ongoing inappropriate sexual behavior had a care plan intervention for 1:1 supervision that was not being implemented; the resident was observed without 1:1 supervision, an RN reported the behaviors occurred daily and that 1:1 supervision had not been provided for an extended period, and the DON confirmed the absence of the ordered supervision.
Surveyors identified that nursing staff failed to provide quality care when an LPN administered medications to residents without explaining the medications or offering information, and an RN administered medications without drawing the privacy curtain in a shared room, allowing a roommate to observe. Policy required privacy during medication administration, and the DON stated residents should be offered information about their medications to support choice and refusal. Surveyors also found urinals filled with urine left on a nightstand and a bed, and a trash can under a sink partially filled with coffee-colored water and trash for several days, despite the Lead GNA stating that GNAs are responsible for emptying urinals every two hours and as needed.
Two residents receiving Morphine Sulfate for pain management had discrepancies between the number of doses signed out and those documented as administered on the MAR, with several doses lacking documentation and no corresponding nursing assessments of effectiveness. Nursing staff were unaware of the missing documentation, and the facility's pain management policy requirements for documentation and monitoring were not met.
A dependent resident with quadriplegia and an above-the-knee amputation, who required two-person assistance for Hoyer lift transfers, was transferred by a single GNA. During the transfer, the Hoyer lift struck the bed, causing the resident to slip through the sling and fall, resulting in bilateral sacral fractures and an L2 compression fracture. Staff interviews and documentation revealed that short staffing contributed to the failure to follow the care plan, with GNAs sometimes performing Hoyer transfers alone.
A resident with quadriplegia suffered physical injury and worsened PTSD after a ceiling collapsed in their room when a pipe burst due to inadequate attic temperature control and lack of pipe insulation. The resident was trapped under water, insulation, and drywall until staff arrived, resulting in ongoing pain, a mild disc bulge, and increased psychological distress.
A resident with hemiplegia was found in bed without access to their call light, which was on the floor instead of within reach as required by their care plan. The resident stated that a staff member had removed the call bell due to frequent use, despite care plan instructions to keep it accessible and encourage its use for assistance.
Staff did not promptly notify a physician when a resident experienced a significant decline, resulting in delayed assessment and intervention. In a separate case, multiple medication changes for another resident were made without notifying the resident's representative, as confirmed by medical record review and facility leadership.
A resident with severe cognitive impairment was found with a swollen, bruised eye, and the facility did not report the injury of unknown origin to OHCQ within the required 2-hour window. The cause of the injury was unclear at the time it was discovered, and the delay in reporting was confirmed by facility leadership.
A resident alleged theft of money, a gift card, and gift certificates from their room. The facility's investigation included statements from GNAs, the previous DON, and leadership staff, but failed to obtain input from nurses, prior shift staff, housekeeping, maintenance, or dietary staff who had access to the room. The NHA and ADON acknowledged that more staff should have been interviewed.
Facility staff did not hold required quarterly care plan meetings for a resident, despite completing quarterly MDS assessments. The last documented care plan meeting was several months prior, and both staff and the resident confirmed that no meetings had occurred during the expected periods.
A resident with cardiac conditions received Metoprolol Tartrate on multiple occasions when either blood pressure or heart rate was below the physician-ordered parameters. Staff misunderstood the order, administering the medication when only one parameter was out of range, rather than holding it as directed. The physician later clarified the order should have been followed for either parameter.
A resident with a history of stroke and hemiplegia had incomplete and inaccurate medical records, including missing diagnoses and lack of documentation of care plan meetings and discussions about loss of nursing home level of care. Key information was not included in the official record, and some documentation was not properly uploaded.
The facility did not follow its plan of correction for three previously identified deficiencies, with one deficiency remaining out of compliance. Although monthly QA meetings were held, the QA team did not specifically discuss the citations or progress of the corrective actions, contrary to what was outlined in the plan. Ongoing concerns were also noted regarding a qualified social worker.
The facility failed to maintain sufficient staffing to meet the needs of its 81 residents, leading to issues such as delayed assistance with ADLs and call light responses. Residents and staff reported concerns about inadequate staffing, with some residents missing scheduled care and staff struggling to complete assignments. The DON and Regional Director acknowledged the staffing shortages and efforts to incentivize staff to cover shifts.
The facility did not complete annual performance reviews for five GNAs, potentially affecting the care of 80 residents. Personnel files showed that GNAs hired between September 2021 and March 2023 missed evaluations. Interviews with HR, administration, and nursing leadership confirmed the oversight, attributed to nurse leadership turnover.
The facility failed to serve food at a palatable and appetizing temperature, affecting all residents consuming meals from the kitchen. Residents with intact cognition reported dissatisfaction with the taste and temperature of meals, including unappetizing eggs and cold, tasteless food. Observations confirmed these issues, with meals lacking flavor and desserts being dry, contrary to the facility's policy on providing a nourishing and well-balanced diet.
The facility failed to maintain sanitary conditions in the kitchen, affecting food preparation and serving for all residents. Observations revealed unsanitary conditions around the ice machine and kitchen equipment, with a lack of adherence to cleaning schedules. Interviews indicated that maintenance tasks were not completed as required, and a dietary aide was found not wearing a facial hair restraint, violating FDA Food Code requirements.
The facility failed to maintain a sanitary garbage and refuse area, with disposable gloves and a trash bag with a hole found around dumpsters. The Dietary Manager, a housekeeper, and the Administrator had differing views on who was responsible for maintaining the area. The facility's policy required the area to be kept clean to minimize debris and pest attractions.
The facility failed to use appropriate PPE during catheter care for residents, with staff unaware of Enhanced Barrier Precautions (EBP) requirements. A resident with an indwelling urinary catheter and another with a drug-resistant UTI did not receive care with the necessary PPE, despite orders for EBP. Additionally, the facility lacked a water management program, increasing the risk of Legionella infection.
The facility did not provide the required 12 hours of in-service training for five GNAs, as mandated by their policy. Personnel files showed that GNAs with start dates from September 2021 to March 2023 had not completed the necessary training. Interviews with facility leadership confirmed the deficiency, which could affect the safety and care of 80 residents.
The facility failed to maintain a sanitary and comfortable environment, with black mold and structural damages observed in multiple rooms. Staff and residents reported that maintenance issues were not addressed, and the Regional Director of Maintenance confirmed the need for significant repairs.
The facility failed to implement its abuse policy for allegations involving a resident who reported rough care and threats by a GNA. The investigation was delayed, and the abuse was not reported immediately. Additionally, the facility could not account for missing narcotics involving two residents, with an incomplete investigation lacking resident and staff statements.
The facility failed to investigate allegations of abuse and missing narcotics for several residents. One resident reported rough treatment and threats from a GNA, but the investigation was delayed, and the GNA was not immediately removed from care. Missing narcotics for two residents were not thoroughly investigated, and a new injury for another resident was not investigated, leaving the cause undetermined.
A facility failed to notify a resident's responsible party when a new treatment was started for a Stage 3 pressure ulcer. The resident was readmitted with a pressure ulcer, and treatment orders were documented, but there was no record of notification to the responsible party. This was confirmed by the DON.
A resident was readmitted to the facility with a stage 3 pressure ulcer on the coccyx. Despite treatment orders being placed, the wound dressing was not started until several days later, resulting in a gap in care. This deficiency was confirmed by the DON.
The facility did not have a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week, on four specific days. This deficiency was confirmed through staffing documentation and an interview with the Regional Director of Labor Management. Complaints from residents, staff, and families about low staffing were also reviewed during the survey.
The facility failed to maintain complete and accurate medical records for three residents, as care plan meetings were not included in their records despite being documented on paper. The Social Services Assistant admitted to keeping evidence of these meetings in her office and uploading them when possible, which was confirmed by the DON.
The facility failed to treat two residents with dignity and respect. A resident with cognitive intactness reported that staff did not knock or introduce themselves before entering her room, and a CMA was observed rolling her eyes at the resident. Another resident with severe cognitive impairment was left uncovered and exposed during care, despite expressing that she was cold. The Interim DON confirmed that staff should knock before entering rooms and cover residents during care.
A resident with morbid obesity was not provided with the appropriate size of incontinent briefs, despite her repeated requests and visible discomfort. The facility staff measured her for a large size but supplied a smaller size, leading to pain and difficulty in sitting. Staff interviews confirmed the resident's need for a larger size, but the facility did not address the issue adequately.
A resident's grievance about another resident's behavior was not promptly resolved due to a lack of follow-up and communication among staff. The grievance, documented during a resident council meeting, was forgotten after being handed to a former DON, leading to unresolved issues and potential for further grievances.
A facility failed to transmit a Death in Facility MDS assessment for a resident within the required timeframe. Although the assessment was completed on time, the MDS Coordinator sent it to corporate offices for batch transmission, and the exact submission date was unknown. The CMS manual requires transmission within 14 days of the MDS death date, which was not met.
A facility failed to create a care plan for a resident with an indwelling urinary catheter, leading to its use for seven months without a discontinuation plan. The resident, cognitively intact, was unsure of the catheter's purpose. Initially ordered for one-day use due to urinary retention, the catheter remained due to a lack of follow-up and delayed urology consultation. The medical record lacked a care plan, and the DON confirmed this oversight.
A facility failed to integrate hospice care into a resident's care plan and did not include all necessary interdisciplinary team members in care planning meetings. Additionally, the facility missed quarterly care plan meetings for several residents, indicating a lack of coordination and adherence to care planning protocols.
A resident with dysphagia experienced significant weight loss, prompting a physician's order for weekly weights. However, the facility failed to document weights on two specified dates, as confirmed by the Interim DON.
The facility failed to provide necessary grooming services for two residents, resulting in inadequate ADL care. One resident, with morbid obesity, was not offered showers due to size limitations of the shower equipment, while another resident, with stroke-related paralysis, did not receive scheduled showers due to equipment issues and staffing shortages. Both residents were dependent on staff for bathing, and the facility's lack of communication and maintenance follow-up contributed to the deficiency.
A facility failed to ensure the safety of a designated smoking area for a resident, as required by its policy. Observations revealed no protective cover over the area and a metal container for ashtrays filled with trash. The resident, who was cognitively intact and smoked regularly, had not experienced any accidents, but the conditions were acknowledged by staff as non-compliant and potentially unsafe.
A facility failed to manage urinary catheter care for a resident, leading to multiple UTIs and delayed urology consults. The resident's catheter was not removed promptly despite physician orders, and a voiding trial was not conducted. Additionally, another resident received improper catheter care, as staff did not follow the facility's policy. These deficiencies were confirmed by the facility's Interim DON.
A facility failed to limit the use of PRN psychotropic medication for a resident with anxiety disorder and moderately impaired cognition. Lorazepam was prescribed beyond the 14-day limit without documented rationale, and the facility lacked a policy addressing this limitation. Despite a recommendation from the consultant pharmacy to discontinue the medication, it was overlooked, leading to a deficiency in the resident's medication regimen.
A resident with an indwelling urinary catheter experienced a seven-month delay in obtaining a urology consult, despite a physician's order. The catheter was initially placed due to urinary retention and possible neurogenic bladder. The delay resulted in continued catheter use without appropriate indication, leading to recurrent urinary tract infections. The resident, who was cognitively intact, was unsure of the catheter's purpose and had requested a delay in its removal. The catheter was eventually removed following a physician's order.
A resident reported her electric bed was broken, and inspection revealed the headboard and footboard were not securely attached, creating a safety hazard. The facility's maintenance system required monthly inspections, which had not been completed in over six months. The resident's cognition was intact, and the deficiency was confirmed by the Regional Director of Maintenance and the Administrator.
A resident with dementia was punched by another resident known for aggression, but the incident was not reported or investigated by the facility. Staff interviews revealed a lack of awareness and communication, and the facility's abuse reporting policy was not followed.
The facility failed to timely report allegations of abuse, neglect, and theft for several residents, increasing the risk of continued harm. A resident reported physical and verbal abuse by a GNA, but the DON delayed reporting to the state agency. Another resident with dementia alleged sexual abuse, but the police were not contacted. Unexplained bruising on a resident was reported late, and a resident's hand fracture was not investigated as a new injury. Additionally, a resident's missing bank card was not reported within the required timeframe.
Failure to Provide and Document Required Overnight Care Resulting in Resident Neglect
Penalty
Summary
The deficiency involves a failure to ensure that a resident remained free from neglect when required care was not provided during an overnight shift. A facility-reported incident submitted to the Office of Health Care Quality documented an allegation by Resident #75 that no staff provided care during the 11 p.m. to 7 a.m. shift on a specific date. A follow-up investigation form in the facility’s incident folder confirmed that the assigned Geriatric Nursing Assistant (GNA) did not enter the resident’s room to provide care during that shift. Review of the GNA task documentation for that night showed no entries for multiple care tasks, including bathing, bed mobility, oral hygiene, toileting, application of barrier cream after incontinence care, bowel elimination, urinary incontinence care, or use of foam ankle boots in bed as tolerated. During an interview, the Director of Nursing stated that care provided during a shift must be documented by the GNA, that there should not be blank spaces on the GNA task documentation, and that refusals and all care-related activities should be recorded. She acknowledged that if a task was not documented, there was no support to show it was completed, and confirmed that if care had been provided to the resident on that night shift, it should have been documented and not left blank.
Failure to Investigate and Document Resident Neglect Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and respond to allegations of neglect made by a resident. Medical record review showed that a hospital consult report, uploaded into the resident’s chart on 12/13/2025, documented that the resident went to the Emergency Department and reported being constantly neglected by the 11 p.m. to 7 a.m. shift, frequently sitting in urine, and having call bells purposely ignored, leading the resident to call 911 for help. The Administrator stated he was not aware of this complaint or of any investigation related to it, despite confirming that such reports of neglect should be brought to his attention and investigated, and that the Emergency Department note had been uploaded by facility staff. The DON reported that the admitting nurse should have reviewed the discharge paperwork when the resident returned from the hospital and should have noted the resident’s complaint of neglect. A second deficiency component was identified through review of Facility Reported Incident #2690114, in which the same resident had reported an allegation of neglect and being left in soiled conditions for an extended period. The DON could only provide the initial incident report submitted to the Office of Health Care Quality and was unable to locate any additional documentation or an investigation file for this incident. She stated that a file containing interviews and evidence is normally maintained for each Facility Reported Incident and confirmed that such a folder should exist for this resident but could not be found. The Administrator similarly confirmed that investigation notes and interviews are kept in a folder in a file cabinet and that the previous DON had handled the investigation for this incident, but the investigation file could not be located.
Missed Care Plan Reviews and Failure to Implement 1:1 Supervision Intervention
Penalty
Summary
The facility failed to hold required quarterly care plan meetings for one resident and failed to implement a care plan intervention for another resident. For Resident #75, interview on 03/10/2026 revealed the resident denied having regular care plan meetings. Medical record review on 03/11/2026 showed documented care plan meetings on 12/04/2024, 09/17/2025, and 01/16/2026, with no additional meetings documented between 12/04/2024 and 09/17/2025. The Regional Social Worker confirmed on 03/11/2026 that no care plan meetings were held for this resident between 12/04/2024 and 09/17/2025 and acknowledged that meetings due in March and June 2025 were missed. For Resident #1, the facility did not implement a care plan intervention for inappropriate sexual behavior. Progress notes reviewed on 03/11/2026 documented multiple occasions of inappropriate sexual behavior. The resident’s care plan, reviewed the same day, included an intervention for 1:1 supervision related to this behavior. However, observation on 03/11/2026 at 10:33 AM found the resident on the unit without 1:1 supervision. In an interview on 03/10/2026, an RN stated the resident continued to display inappropriate behaviors with other residents daily and that 1:1 supervision had not been in place for “maybe 2 months.” On 03/13/2026, the DON acknowledged that the resident displayed inappropriate sexual behavior and did not currently have 1:1 supervision as specified in the care plan.
Failure to Provide Informed, Private Medication Administration and Basic Hygiene Care
Penalty
Summary
The deficiency involves failures in medication administration practices and basic care related to hygiene and environmental cleanliness. Surveyors observed an LPN administering medications to two residents without explaining the medications or offering the opportunity for the residents to be informed. In a separate observation, an RN administered medications to a resident in a shared room without providing privacy, as the privacy curtain was not drawn and the roommate was able to observe the process. Review of the facility’s medication administration policy showed that providing privacy is required, and the DON stated that staff are expected to offer residents the opportunity to be informed about their medications to support resident choice and the ability to refuse. Additional deficiencies were identified in the management of residents’ urinals and room cleanliness. Surveyors observed two urinals filled with urine on a nightstand in one resident’s room, and the resident reported that some aides empty the urinal and some do not, and that this situation happens all the time. In another room, a urinal filled with urine and a trash can were observed on the bed. During room rounds, a trash can under a sink was found to be approximately one-quarter full of coffee-colored water and trash, and a resident stated it had been there for a couple of days. The Lead GNA reported that GNAs are responsible for emptying residents’ urinals every two hours and as needed, confirming that ensuring urinals are emptied is part of their duties.
Incomplete Medication Documentation for Pain Management
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents, as evidenced by discrepancies between the controlled medication utilization records and the medication administration records (MAR) for Morphine Sulfate. For one resident with diagnoses including anxiety, dementia, and atrial fibrillation, the pain management care plan required administration and documentation of analgesic medications as ordered, with monitoring and documentation of side effects and effectiveness every shift. However, a review of the resident's records revealed that 34 doses of Morphine Sulfate were signed out in November, but only 26 doses were documented as administered on the MAR. Several specific dates were identified where doses were not documented, and there was no corresponding nursing assessment of the medication's effectiveness in the progress notes. Similarly, for another resident with chronic pain, lumbar back pain, repeated falls, and muscle wasting, who was also receiving hospice services, the controlled medication utilization record showed 35 doses of Morphine Sulfate signed out over a specified period, but only 14 doses were documented as administered on the MAR. Multiple dates were identified where documentation was missing, and there was no evidence in the MAR or nursing progress notes of any assessment regarding the effectiveness of the administered medication. Interviews with nursing staff revealed a lack of awareness regarding the missing documentation for both residents. The staff nurse interviewed was not aware of the failure to sign off on administered doses and confirmed the existence of both standing and as-needed orders for Morphine Sulfate. The facility's pain management policy required collaboration with healthcare professionals and documentation of interventions, but the records reviewed did not reflect compliance with these requirements.
Failure to Follow Two-Person Hoyer Transfer Protocol Results in Resident Injury
Penalty
Summary
Facility staff failed to follow the established plan of care for a dependent resident with quadriplegia and an above-the-knee amputation, resulting in significant injury during a transfer. The resident, who was totally dependent for all activities of daily living and required a Hoyer lift with assistance from two staff members for transfers, was instead transferred by a single geriatric nursing assistant (GNA). The GNA used the resident's own sling but did not have a second staff member present, as required by the care plan. During the transfer from bed to chair, the wheel of the Hoyer lift struck the end of the bed, causing the resident to slip through the sling and fall to the floor, landing on the buttocks. Following the fall, the resident complained of back pain and was subsequently transferred to the hospital, where imaging revealed bilateral sacral fractures and an L2 compression fracture. The resident was alert but not at full baseline, likely due to pain and lack of sleep after spending the night in the emergency room. Staff interviews confirmed that the GNA was working alone at the time of the transfer, despite the care plan's requirement for two-person assistance. Other staff members reported that short staffing was common, and it was not unusual for GNAs to perform Hoyer transfers alone when the facility was understaffed. Documentation and interviews indicated that the unit was short-staffed on the day of the incident, with GNAs assigned to multiple units and responsible for a high number of residents, many of whom required total care. The nurse on duty and other GNAs corroborated that the transfer was performed by one person, and that this practice had occurred previously due to staffing shortages. The failure to adhere to the resident's care plan and provide adequate supervision during the transfer directly resulted in the resident's injuries.
Ceiling Collapse Causes Physical and Psychosocial Harm Due to Environmental Failure
Penalty
Summary
The facility failed to maintain a safe and functional environment, resulting in both physical and psychosocial harm to a resident. On the date of the incident, a pipe burst in the attic above a resident's room due to inadequate temperature control and lack of pipe insulation, causing the ceiling to collapse onto the resident. The resident, who has quadriplegia and fully intact cognitive function, was unable to move independently and was covered in water, insulation, and drywall until staff arrived several minutes later to remove them from the room. Medical records indicate that the resident was sent to the emergency room, where they were evaluated for injuries and subsequently diagnosed with cervical spine and lumbar strain, leading to ongoing pain management with various medications, including Oxycodone and later Suboxone. The resident continued to experience significant lower back pain, which was later associated with a mild disc bulge found on MRI. The incident also exacerbated the resident's pre-existing PTSD, as documented in psychological and psychiatric evaluations, with the resident expressing ongoing fear and trauma related to the event. Interviews with staff confirmed that the ceiling collapse was sudden and involved a large section of drywall, insulation, and water falling directly onto the resident. Staff described the resident as visibly upset and shaken after the incident. The resident later requested counseling and physical therapy services from providers not affiliated with the facility, citing feelings of unsafety and worsened PTSD symptoms following the event. The deficiency was directly linked to the facility's failure to maintain appropriate environmental controls to prevent pipe freezing and rupture.
Call Light Not Accessible to Resident with Hemiplegia
Penalty
Summary
A deficiency was identified when a resident with hemiplegia was observed lying in bed without access to their call light, which was found on the floor in front of the oxygen concentrator. The resident reported that the call bell was usually placed on the bed but had been removed by a staff member because the resident was using it frequently. The resident's care plan included interventions to encourage the use of the call bell for assistance and specifically directed that the call light be kept within reach on the resident's right side. Despite these documented interventions, the call light was not accessible to the resident at the time of observation, and the resident had to request assistance from the surveyor to retrieve a personal item.
Failure to Notify Physician of Change in Condition and Representative of Medication Changes
Penalty
Summary
Facility staff failed to promptly notify a physician when a resident experienced a significant change in condition. One resident with a history of traumatic brain injury, heart failure, and renal failure was noted as difficult to arouse and lethargic by a nurse, but no timely assessment or notification to the physician occurred. Multiple staff members, including a registered nurse and a geriatric nursing assistant, observed the resident to be unresponsive and reported that the assigned LPN had not taken immediate action or obtained vital signs. The resident was eventually found to have critically low blood pressure and was transferred to the hospital after emergency measures were initiated, but only after a significant delay and repeated prompting by other staff members. Additionally, the facility failed to notify a resident's representative when there were multiple changes to the resident's medication regimen. Medical record review showed several instances where antipsychotic and anti-anxiety medications were initiated or had their dosages increased, but there was no documentation that the resident's representative was informed of these changes. The Assistant Director of Nursing confirmed the lack of documentation regarding representative notification for these medication changes.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required 2-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). A staff nurse became aware of a resident with severe cognitive impairment who was found with a swollen, bruised left eye. The resident was unable to communicate the cause of the injury. The initial self-report to OHCQ was sent the following morning, more than 2 hours after the injury was discovered. Facility leadership confirmed that at the time, it was unclear whether the injury was due to a fall, being hit, or another cause.
Failure to Thoroughly Investigate Alleged Misappropriation of Property
Penalty
Summary
The facility failed to provide adequate documentation that an allegation of misappropriation of property was thoroughly investigated. Specifically, a resident reported that money, a gift card, and multiple gift certificates were stolen from their room during a specified time frame. The facility's investigation included written statements from three geriatric nursing assistants, the previous DON, and three other staff in leadership positions. However, the investigation did not include interviews or statements from nurses on duty, staff from previous shifts, housekeeping, maintenance, or dietary staff who also had access to the resident's room. During interviews, the NHA and ADON confirmed that additional staff should have been interviewed as part of the investigation process.
Failure to Hold Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to conduct required quarterly care plan meetings for a resident, as evidenced by medical record review and staff interviews. The resident was admitted in November 2022, and while quarterly MDS assessments were completed in March and June 2025, there was no documentation or evidence of corresponding care plan meetings during those periods. The last recorded care plan meeting for the resident occurred in December 2024. Interviews with the Social Services Assistant and the Assistant Director of Nursing confirmed the absence of care plan meetings in March and June 2025. Additionally, the resident reported not having any care plan meetings during the year and had been requesting them.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication Administration
Penalty
Summary
A deficiency occurred when a resident with multiple cardiac and vascular diagnoses, including non-rheumatic aortic stenosis, hypertension, atrial fibrillation, and heart disease, received Metoprolol Tartrate despite physician orders specifying parameters for administration. The physician's order directed staff to hold the medication if the resident's blood pressure was less than 110/65 or if the heart rate was less than 65. However, medical record review revealed multiple instances over several months where the medication was administered even when the resident's blood pressure or heart rate was below the specified thresholds. Staff interviews confirmed a misunderstanding of the physician's order, with staff indicating they would only hold the medication if both blood pressure and heart rate were below parameters, rather than either one. The physician clarified during the survey that the medication should have been held if either parameter was below the threshold. The facility's failure to follow the physician's order resulted in the resident receiving unnecessary medication doses outside of the prescribed parameters.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a history of cerebral infarction and hemiplegia. Upon review, it was found that the resident's medical record did not include all relevant diagnoses, specifically omitting hemiplegia on the information sheet submitted for nursing home level of care appeal. Instead, the documentation listed a diagnosis of no residual deficit, which did not accurately reflect the resident's condition. Additionally, the documentation provided for the appeal did not include all of the resident's diagnoses, and the information sheet was incomplete. Further review revealed that the facility did not maintain up-to-date records of care plan meetings and discussions regarding the resident's loss of nursing home level of care. There was no evidence in the medical record of a care plan meeting after April, nor documentation of discussions with the resident and their representative about the loss of level of care. Although a care plan meeting was held in July, the documentation was kept in the Social Services Assistant's office and had not been uploaded to the medical record, resulting in incomplete official records.
Failure to Follow Plan of Correction and Monitor Quality Deficiencies
Penalty
Summary
The facility failed to correct and monitor previously identified quality deficiencies, as evidenced by a revisit survey that found noncompliance with three specific deficiencies (F610, F842, and S1320). Record review and staff interviews revealed that the facility did not follow its plan of correction for these deficiencies, with S1320 remaining out of compliance. The Director of Nursing identified the Administrator as the Quality Assurance (QA) contact person, and the Administrator confirmed that QA meetings were held monthly. However, when questioned, the Administrator stated that the QA team did not specifically discuss the citations or the progress of the plan of correction, despite the plan indicating that the QAPI team would review all audits. The surveyor noted ongoing concerns related to a qualified social worker.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its 81 residents, as evidenced by multiple observations and interviews with residents and staff. Several residents, including those identified as R15, R44, and R55, reported issues related to inadequate staffing, such as not receiving timely assistance with activities of daily living (ADLs) and delayed response to call lights. R15, who required assistance from two staff members, expressed concerns about the lack of staff, while R44 noted that she sometimes missed her scheduled baths due to insufficient staffing. R55 also highlighted difficulties in getting assistance on weekends. These issues were corroborated by the facility's Minimum Data Set (MDS) assessments, which indicated that these residents were cognitively intact and aware of the staffing deficiencies. Staff interviews further confirmed the staffing inadequacies, with Geriatric Nurse Aides (GNAs) and a Registered Nurse (RN) expressing concerns about their ability to complete assignments and ensure resident safety. GNAs reported being unable to monitor all residents effectively, especially when only one aide was assigned to a unit. The RN mentioned working double shifts and being the only nurse on duty during certain shifts, which heightened his anxiety about resident safety. The Director of Nursing (DON) and the Regional Director of Labor Management acknowledged the staffing shortages, noting efforts to incentivize staff to cover shifts, but admitted that the facility was struggling to maintain adequate staffing levels.
Failure to Conduct Annual GNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for five Geriatric Nurse Aides (GNAs), which could potentially impact the safety and care of all 80 residents. Personnel files revealed that GNAs with start dates ranging from September 2021 to March 2023 had not received their required annual evaluations. Interviews with the Human Resources Director, Administrator, Director of Nursing, Chief Nursing Officer, and President of Clinical Operations confirmed that the evaluations were not completed due to nurse leadership turnover. The Chief Nursing Officer had implemented a directive for annual evaluations in January 2024, but it was not followed, leading to the deficiency.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature, as observed during two meal tray observations. This deficiency potentially affected all 80 residents who consumed food prepared by the facility's kitchen. During the initial screening, several residents expressed dissatisfaction with the taste and temperature of the food. Interviews with residents revealed specific complaints about the quality of meals, including unappetizing eggs, hard meat, and half-baked toast. These residents had intact cognition, as indicated by their BIMS scores, which ranged from 13 to 15 out of 15. Further observations during a group meeting and review of resident council minutes highlighted ongoing issues with food quality. Residents consistently reported that meals were cold and tasteless. A tray observation revealed that while some items were warm, they lacked flavor, and the dessert was dry. The facility's policy on Food and Nutrition Services, revised in October 2017, stated that each resident should receive a nourishing, palatable, well-balanced diet, considering their preferences. However, the facility did not adhere to this policy, as evidenced by the residents' complaints and the observations made during the survey.
Sanitation Deficiencies in Kitchen and Food Handling
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting the preparation and serving of food to all 80 residents. During an initial kitchen tour, it was observed that the ice machine compressor was covered with a white powdery substance, and the floor around it was littered with trash, debris, and spider webs. The ice scoop holder contained water with a brown, gritty appearance, and the ice chest had a blackish-brown substance. Additionally, the floor and baseboards around kitchen equipment were covered with a greasy, dark sticky substance, and the tile grout appeared discolored. The hood vent had not been cleaned since February 2024, despite being due for cleaning in August 2024, and had a visible buildup of grease. Interviews with the Dietary Manager and the Regional Director of Maintenance revealed a lack of adherence to cleaning schedules and maintenance responsibilities. The Dietary Manager stated that the maintenance director was responsible for the ice machine's cleanliness, while the Regional Director of Maintenance acknowledged that scheduled maintenance tasks were not completed as required. Furthermore, during a tray line observation, a dietary aide was found not wearing a facial hair restraint, contrary to FDA Food Code requirements. The facility's policy on ice machines emphasized the need for proper cleaning and maintenance to prevent microbial contamination, which was not being followed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a kitchen tour with the Dietary Manager (DM). Three green dumpsters were located on a grass pad, surrounded by disposable gloves and a clear plastic trash bag with a hole, containing gloves, napkins, and food wrappers. The DM indicated that maintaining the garbage area was a housekeeping task, although dietary staff would pick up trash if found. The cleaning schedule for dietary staff did not include responsibility for the garbage area. A housekeeper believed maintenance was responsible, but all staff should clean around the dumpsters. The Administrator thought both dietary staff and housekeeping were responsible. The facility's policy stated that the surrounding area should be kept clean to minimize debris and insect/rodent attractions, and garbage should not accumulate outside the dumpster.
Inadequate PPE Use and Lack of Water Management Program
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically in the use of personal protective equipment (PPE) during catheter care for residents. Resident 65, who was readmitted with a diagnosis of obstructive and reflux uropathy, was observed receiving catheter care without the appropriate PPE. The Geriatric Nursing Assistant (GNA) 4 only wore gloves and did not don a gown, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. The Interim Director of Nursing (DON) confirmed that the necessary PPE was not available outside Resident 65's room, and staff were not aware of the EBP requirements for residents with indwelling urinary catheters. Similarly, Resident 11, who had a physician's order for EBP due to an indwelling urinary catheter, did not have the required signage or PPE available. Licensed Practical Nurse (LPN) 3 and GNA17 provided care without wearing gowns, and there was confusion about the status of the EBP order. Resident 33, diagnosed with a drug-resistant urinary tract infection, had signage and PPE available, but GNA6 did not use a gown during care, indicating a lack of awareness about the resident's infection control needs. Additionally, the facility lacked a water management program, which is crucial for preventing Legionella infections. The Regional Director of Maintenance confirmed the absence of such a program and was unaware of any concerns related to Legionella. This oversight places all residents at risk, highlighting significant gaps in the facility's infection control measures.
Failure to Provide Required In-Service Training for GNAs
Penalty
Summary
The facility failed to provide the required 12 hours of in-service training for five Geriatric Nurse Aides (GNAs), which is necessary to ensure their continuing competencies. This deficiency was identified through interviews, personnel files review, and policy review. The facility's policy mandates that 12 hours of in-service training be provided annually based on the employment date. However, the personnel files of GNAs with start dates ranging from September 2021 to March 2023 revealed that they had not completed the required training. Interviews with the Human Resources Director, Administrator, Director of Nursing, Chief Nursing Officer, and the President of Clinical Operations confirmed that the training was not being provided. This lapse had the potential to impact the safety and care of 80 residents in the facility.
Facility Maintenance and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to maintain a sanitary, orderly, and comfortable environment, as evidenced by the presence of black mold and other maintenance issues across multiple rooms. During an environmental tour, several deficiencies were observed, including black mold in rooms 408, 410, 400, 307, and 205, as well as structural damages such as unpainted spackle, holes in walls, and missing base molding. Additionally, there were issues with rusted fixtures, chipped counters, and missing covers for smoke detectors and ventilation fans. These conditions were confirmed by the Regional Director of Maintenance during a tour. Interviews with staff and residents revealed that maintenance issues had been reported but not addressed. A staff member indicated that the maintenance personnel had not performed their duties the previous week, and a resident reported that complaints about mold were ignored by the Maintenance Director. The resident had even marked the mold location with a sticky note, highlighting the lack of response to maintenance requests. The Regional Director of Maintenance acknowledged the findings and the need for significant repairs.
Failure to Implement Abuse Policy and Investigate Missing Narcotics
Penalty
Summary
The facility failed to fully implement its abuse policy in response to allegations of physical and verbal abuse, as well as misappropriation of property, involving three residents. One resident reported that a Geriatric Nursing Assistant (GNA) was rough during care and made threatening statements regarding the resident's diaper. The resident, who was cognitively intact and dependent on staff for toileting, expressed fear and reported soreness in his arms and neck. Despite the resident's report, the facility's investigation was delayed, and the abuse allegation was not reported immediately as required by the facility's policy. The investigation into the abuse allegation was initiated after a written statement was found under the Director of Nursing's (DON) door. The DON was informed of the incident via text message the previous evening but did not take immediate action to report the allegation. The investigation included obtaining statements from the involved staff, but the facility was unable to substantiate the abuse claims due to contradictory statements and lack of physical evidence. The resident was placed on daily safety checks, but the investigation did not include comprehensive interviews with all potential witnesses or other residents. In a separate incident, the facility failed to account for missing narcotics involving two residents. The investigation into the missing medications was incomplete, lacking written statements from the affected residents or other staff. The facility conducted an audit and background checks but was unable to determine the cause of the missing narcotics. The administrative staff involved in the incident were no longer employed at the facility, and the Interim DON was unfamiliar with the case, indicating a lack of continuity in addressing the issue.
Failure to Investigate Abuse and Missing Narcotics
Penalty
Summary
The facility failed to investigate allegations of physical and verbal abuse, as well as misappropriation of property, in a timely and thorough manner for several residents. One resident reported an incident where a Geriatric Nursing Assistant (GNA) was rough during care and made threatening remarks. Despite the resident being cognitively intact and dependent on staff for toileting, the facility did not initiate a care plan for behaviors upon admission. The investigation was delayed, and the alleged perpetrator was not immediately removed from the resident's care, leaving the resident and others at risk. In another incident, the facility did not adequately investigate missing narcotics for two residents. The medications were unaccounted for, and the facility was unable to determine what happened. The investigation lacked written statements from the involved residents or staff, and the administrative staff at the time of the incident were no longer employed, leaving gaps in the investigation process. Additionally, the facility failed to investigate a new injury for a resident who was found with a hairline fracture and bruising on the hand. Despite the physician's documentation indicating no known cause for the injury, the facility did not conduct an investigation, as they believed it was related to a previous fall. This lack of investigation left the cause of the injury undetermined.
Failure to Notify Responsible Party of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to notify a resident's responsible party when a new treatment was initiated for a pressure ulcer. This deficiency was identified during a review of the medical records and staff interviews, specifically concerning a resident who had been readmitted to the facility after a hospital stay. Upon readmission, the nursing admission assessment noted the presence of a pressure ulcer on the coccyx, but the length, width, depth, and stage were initially undetermined. Subsequent documentation on a wound note indicated that the resident had a Stage 3 pressure ulcer, and treatment orders were placed to cleanse the area with a wound cleanser, apply medical-grade honey and calcium alginate to the base of the wound, secure it with bordered gauze, and change it daily. However, the medical record did not contain documentation that the responsible party was informed of the Stage 3 pressure ulcer and the treatment plan. This oversight was confirmed during an interview with the Director of Nursing.
Failure to Provide Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide timely treatment and services to prevent or heal pressure ulcers for Resident #65. Upon review of the medical records and staff interviews, it was found that Resident #65 was readmitted to the facility with a pressure ulcer on the coccyx, which was initially unable to be determined in terms of length, width, depth, and stage. A subsequent wound note on 10/25/23 documented that the ulcer was a stage 3 pressure ulcer present on admission, and treatment orders were placed to cleanse the area with a wound cleanser, apply medical grade honey, calcium alginate to the base of the wound, secure with a bordered gauze, and change the dressing daily. However, the review of Resident #65's October 2023 Treatment Administration Record (TAR) revealed that the wound dressing treatment was not initiated until 10/28/23, indicating a gap in treatment from 10/17/23 to 10/28/23. This lapse in care was confirmed during an interview with the Director of Nursing on 10/31/24. The failure to provide timely treatment for the pressure ulcer represents a deficiency in the facility's care for Resident #65.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
The facility failed to maintain the required staffing levels by not having a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified during an annual survey, where it was found that on four specific days, the facility did not have RN coverage as required. The days without RN coverage were January 26, 2024, January 28, 2024, October 5, 2024, and October 20, 2024. This was confirmed through a review of staffing documentation provided by the Regional Director of Labor Management and an interview with the same individual, who acknowledged the lack of RN coverage on these dates. Numerous complaints regarding low staffing from residents, staff, and families were also reviewed during the survey, highlighting the ongoing issue of inadequate RN staffing.
Incomplete Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by accepted professional standards. For Resident #19, the care plan meetings held in March and July 2024 were not included in the resident's medical record, despite evidence of these meetings being available on paper. The Social Services Assistant admitted to keeping evidence of care plan meetings in her office and uploading them to the medical record when possible. This was confirmed by the Director of Nursing, who acknowledged the omission of the March and July 2024 care plan meetings from the medical record. Similarly, for Resident #45, the June 2024 care plan meeting was not documented in the resident's medical record, although evidence was available on paper. The Social Services Assistant again stated that she keeps evidence of care plan meetings in her office and uploads them when she can. The Director of Nursing confirmed the failure to include the June 2024 care plan meeting in the medical record. For Resident #62, the September 2024 care plan meeting was missing from the medical record, despite being documented on paper. The Social Services Assistant's practice of keeping evidence in her office and uploading it when possible was again noted, and the Director of Nursing confirmed the omission of the September 2024 care plan meeting from the medical record.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the treatment of two residents. Resident 14, who was cognitively intact with a BIMS score of 15 out of 15, reported that staff did not knock or introduce themselves before entering her room. During an interview, a Certified Medicine Aide (CMA) entered Resident 14's room without knocking and placed a lunch tray without introduction. Additionally, Resident 14 expressed frustration over the CMA's behavior, including rolling her eyes, which was observed by surveyors. The Interim Director of Nursing confirmed that staff are expected to knock and wait for permission before entering a resident's room and should not roll their eyes at residents. Resident 65, who had a BIMS score of zero indicating severe cognitive impairment, was left uncovered and exposed during a bath and catheter care by a Geriatric Nursing Assistant (GNA). Despite Resident 65 expressing that she was cold multiple times, the GNA did not cover her with a blanket or sheet, leaving her exposed throughout the care process. The Interim Director of Nursing stated that staff are expected to cover residents during care to prevent exposure. These incidents demonstrate a failure to uphold the facility's policy on promoting and maintaining resident dignity.
Failure to Provide Appropriate Incontinent Briefs
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not allowing her to choose the appropriate size of incontinent briefs, which led to discomfort and potential skin issues. The resident, who was readmitted with a diagnosis of morbid obesity, expressed that the current size of briefs was too tight and painful, causing difficulty in sitting up. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident's repeated requests for a larger size over two months were not addressed by the facility. Interviews with staff revealed that the resident was initially measured for a large size, but was provided with a 3x size, which was deemed insufficient by the resident and some staff members. The Medical Records/Central Supply staff decided against providing a larger size after a trial, assuming the resident did not complain further. However, observations confirmed the resident's discomfort, and staff acknowledged the need for a larger size due to the resident's condition as a heavy wetter. The Interim DON acknowledged the issue but did not provide a reason for the failure to supply the correct size.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly resolve a grievance voiced by a resident, R4, during a resident council meeting. R4, who was cognitively intact with a BIMS score of 15, expressed concerns about another resident, R34, being rude due to the toilet not being cleaned properly after use. The grievance was documented on a Council Concern/Recommendation Form, but the form was undated and unsigned, indicating a lack of follow-up. The Activities Director stated that the concern was forgotten because the Director of Nursing, who received the concern, was no longer employed at the facility. Interviews revealed that the Social Services Assistant, who was responsible for ensuring grievances were followed up on, had given the form to the former Director of Nursing and had not seen it since. The Administrator, who oversees all grievances, confirmed that she had not seen the concern from R4 and acknowledged that there should have been more follow-up. This lack of action and communication led to the grievance not being resolved, which had the potential to cause further grievances to remain unresolved for other residents in the facility.
Delayed Transmission of MDS Assessment for Deceased Resident
Penalty
Summary
The facility failed to ensure timely transmission of a Minimum Data Set (MDS) assessment for one resident, identified as Resident 75, out of 31 sampled assessments. The resident was admitted to the facility and subsequently died there. The Death in Facility MDS was completed on time, but the transmission of this assessment was delayed. The MDS Coordinator confirmed that assessments are sent to corporate offices for batch transmission, and she was unaware of the exact submission date, although she sent it immediately. According to the CMS Long-term Care Facility Assessment Instrument 3.0 User's Manual, the transmission should occur no later than 14 days after the MDS death date. The facility's policy also mandates adherence to federal and state submission timeframes.
Failure to Develop Care Plan for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter, resulting in the catheter being in place for seven months without a plan for its discontinuation. The resident, who was cognitively intact, was unsure of the reason for the catheter's placement. The initial physician's order was for a one-day use due to urinary retention, but the catheter remained in place due to a lack of follow-up and a delayed urology consultation. The medical record lacked a care plan addressing the catheter's use and discontinuation, and the Director of Nursing confirmed the absence of such a plan. The resident's medical records indicated a history of urinary retention and recurrent urinary tract infections, with a urology consult initially ordered but not completed until seven months later. The attending physician and medical director acknowledged the lack of medical justification for the prolonged use of the catheter and the delay in attempting a voiding trial. The failure to develop a care plan with specific interventions and goals for the catheter's use and discontinuation was verified by the Director of Nursing, highlighting a significant oversight in the resident's care management.
Deficiencies in Care Planning and Coordination
Penalty
Summary
The facility failed to ensure that a resident receiving hospice care had an integrated care plan, as required by their policies. The resident, identified as R32, was readmitted with a diagnosis of dementia and was under hospice care. However, the care plan did not reflect hospice involvement, and the interdisciplinary team (IDT) meetings did not include all necessary members, such as a hospice nurse and a nurse aide. Interviews with facility staff confirmed these omissions, indicating a lack of coordination and communication in care planning. Additionally, the facility did not conduct quarterly care plan meetings for several residents, including Resident #19, #45, and #65. Resident #19's last care plan meeting was in July 2024, missing the October 2024 meeting. Resident #45 missed multiple quarterly meetings, with no documentation of attempts to hold these meetings without the resident's presence. Resident #65's care plan meetings were not held for nearly a year, with missed opportunities to reschedule when the family was unavailable. These deficiencies highlight a pattern of inadequate care planning and coordination within the facility, potentially affecting the quality of care provided to residents. The lack of timely and comprehensive care plan meetings, as well as the failure to include all relevant parties in the planning process, suggests systemic issues in adhering to care planning protocols.
Failure to Conduct Weekly Weights for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, received weekly weight monitoring as ordered by the physician. R3 was readmitted to the facility with a diagnosis of dysphagia and had experienced a significant weight loss of 14 pounds (11%) over 30 days. The Registered Dietitian recommended weekly weights for closer monitoring, starting on 10/14/24. However, a review of the electronic medical record (EMR) revealed that there was no documentation of weights being taken on 10/14/24 and 10/21/24, as required. This was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the weekly weights were not completed as ordered.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary grooming services for two residents, R15 and R33, as part of their activities of daily living (ADL) care. R15, who was readmitted with a diagnosis of morbid obesity, was observed with greasy hair and white flakes, indicating a lack of proper hair washing. Despite being dependent on staff for bathing and hygiene, R15 was not offered showers due to her size exceeding the capacity of the available shower chair and bed. The Interim Director of Nursing confirmed that R15 had not been offered a shower in the past month, and there was no evidence in the Plan of Coordination that showers were offered or declined. Resident R33, who was admitted with a history of stroke and left-side paralysis, was also not receiving showers as per the facility's schedule. The resident's medical records indicated total dependence on staff for bathing, yet documentation showed only bed baths were provided from June to October 2024. Interviews with staff revealed issues with the availability and functionality of bariatric shower beds and slings, contributing to the lack of showers. R33 expressed fear of falling during the shower process and noted that staff often cited short staffing as a reason for not providing showers. The facility's failure to provide adequate ADL care was further highlighted by the broken shower bed pin, which was not promptly addressed. Staff interviews revealed a lack of communication and follow-up regarding maintenance issues, with the broken pin only being fixed during the surveyor's visit. The DON was informed of the situation, and R33 reiterated a preference for showers during the day shift due to perceived excuses from the evening shift about staffing shortages.
Deficiency in Smoking Area Safety Measures
Penalty
Summary
The facility failed to ensure the designated smoking area was safe for a resident who was the only smoker in the facility. The facility's policy required that the smoking area be protected from weather conditions and have accessible metal containers with self-closing covers for ashtrays. However, during observations, it was noted that there was no protective cover over the smoking area, and the metal container intended for ashtrays was full of trash. This was confirmed by the Regional Director of Labor, the Maintenance Director, and the Administrator in Training, who acknowledged that the conditions did not comply with the facility's smoking policy and could be unsafe when the area was in use. The resident involved, who was cognitively intact and safe to smoke with or without supervision, reported smoking six cigarettes per day at designated smoking times. Despite the lack of accidents related to smoking, the absence of a protective cover and the presence of trash in the metal container were identified as deficiencies. The Administrator also confirmed these observations, agreeing that the metal container should be free of trash before the resident smoked, indicating a failure to adhere to the facility's safety measures for the smoking area.
Deficiencies in Urinary Catheter Management and Care
Penalty
Summary
The facility failed to appropriately manage the urinary catheter care for a resident, identified as R11, who experienced multiple urinary tract infections (UTIs) while having an indwelling urinary catheter. Despite a physician's order to discontinue the catheter and monitor voiding, the catheter was not removed until a later date. The resident had a history of urinary retention and was initially given a catheter due to complaints of not being able to empty the bladder. However, a voiding trial was not attempted earlier, and a urology consult was delayed for several months, which contributed to the prolonged use of the catheter and recurrent UTIs. Additionally, the facility did not provide a policy for urinary catheter use when requested by surveyors. The medical records revealed multiple instances of UTIs treated with antibiotics, and the attending physician expressed concerns about antibiotic resistance. The Medical Director noted that there was no medical indication for the prolonged use of the catheter and that a voiding trial should have been conducted earlier. In another instance, the facility failed to provide proper catheter care for another resident, identified as R65. During an observation, a Geriatric Nursing Assistant (GNA) did not follow the facility's catheter care policy, which included not cleaning the labia area properly and not changing the direction of the washcloth. This was confirmed by the Interim Director of Nursing, who acknowledged that the staff did not adhere to the correct procedures for catheter care.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications, specifically regarding the use of PRN psychotropic medications. A resident with a diagnosis of anxiety disorder and moderately impaired cognition was prescribed Lorazepam to be taken as needed every six hours for anxiety. The medication was administered on three occasions in September 2024. However, the facility did not have a policy limiting PRN orders for psychotropic drugs to 14 days, and the medication was prescribed beyond this period without documented rationale. Interviews with the Director of Nursing and the Medical Director revealed that the facility overlooked a recommendation from the consultant pharmacy to discontinue the PRN Lorazepam, which should have been limited to 14 days. The facility's Medication Regimen Review policy required monthly reviews by a licensed pharmacist, but the oversight occurred despite this policy. The deficiency was identified during a review of the resident's electronic medical record and the facility's policies.
Delayed Urology Consult for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to obtain a timely urology consult for a resident with an indwelling urinary catheter, which was initially placed due to urinary retention and possible neurogenic bladder. Despite a physician's order for a urology consult on 03/07/24, the consult did not occur until 10/01/24, resulting in the continued use of the catheter without appropriate indication. The resident, who was cognitively intact, was unsure of the reason for the catheter placement and had expressed a desire to delay its removal until feeling better. The delay in obtaining the urology consult was verified by the Director of Nursing and acknowledged by the attending physician, who was unaware of the reason for the seven-month delay. The medical director also confirmed that the consult should not have taken so long. The resident experienced recurrent urinary tract infections, which the urologist attributed to the chronic use of the indwelling catheter. The catheter was eventually removed on 10/29/24, following a physician's order.
Failure to Maintain Resident's Bed Safety
Penalty
Summary
The facility failed to ensure the safety and maintenance of a resident's bed, which was identified as a deficiency during a survey. A resident reported that her electric bed was broken, and upon inspection, it was found that the headboard and footboard were not securely attached, creating a gap of approximately three to five inches between the mattress and the bed frame. The resident's electronic medical record indicated that her cognition was intact, with a BIMS score of 15 out of 15. The Regional Director of Maintenance confirmed that the loose headboard and footboard posed a safety hazard and acknowledged that the facility's maintenance management system, TELS, required monthly inspections of electric beds, which had not been completed in over six months. The Administrator also confirmed that the beds were to be inspected monthly to prevent safety hazards.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident 39, who has diagnoses including dementia and anxiety disorder, was involved in an altercation with Resident 63, who has Alzheimer's disease and vascular dementia. Resident 63, known to be physically aggressive, punched Resident 39 in the face after Resident 39 wandered into Resident 63's room. Despite the altercation, Resident 39 did not sustain any injuries. The incident was not reported to the facility administration or the State Agency, and no internal investigation was conducted. Interviews with facility staff revealed a lack of awareness and communication regarding the incident. The Administrator and Nurse Practitioner were unaware of the altercation, and the Director of Nursing, who was new to the position, confirmed that no investigation had been initiated. A Registered Nurse and a Geriatric Nursing Assistant witnessed or were informed of the incident but did not ensure it was reported according to facility policy. The facility's policy on reporting abuse was not followed, resulting in a failure to protect the resident from abuse and to take appropriate action following the incident.
Failure to Timely Report Abuse and Neglect Allegations
Penalty
Summary
The facility failed to timely report allegations of physical and verbal abuse for five residents, increasing the risk of continued abuse. Resident 233 reported an incident of physical and verbal abuse by a Geriatric Nursing Assistant (GNA) to a Registered Nurse (RN), who then informed the Director of Nursing (DON) via text message. Despite being notified, the DON did not report the abuse allegation to the state agency until the following morning, exceeding the required two-hour reporting timeframe. The facility's investigation could not substantiate the allegations due to contradictory statements and lack of visible injuries. Resident 32, who has dementia, reported an allegation of sexual abuse to a hospice nurse. The facility conducted interviews and assessments but did not contact the police, which was confirmed by the interim DON as a failure in procedure. Additionally, Resident 28 was found with unexplained bruising, which was not reported to the state agency until several days later. The facility's investigation suggested an unwitnessed fall, but the delay in reporting and lack of immediate investigation were noted as deficiencies. Resident 65 had a hairline fracture and bruising on the hand, which was not reported as a new injury due to a previous fall. The Nursing Home Administrator (NHA) acknowledged that an investigation should have been conducted. Lastly, Resident 62 reported a missing bank card, but the facility failed to report the misappropriation within the required timeframe. These incidents highlight the facility's repeated failures to adhere to timely reporting protocols for abuse, neglect, and theft allegations.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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