Doctors Community Rehabilitation And Patient Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Lanham, Maryland.
- Location
- 6710 Mallery Drive, Lanham, Maryland 20706
- CMS Provider Number
- 215108
- Inspections on file
- 20
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Doctors Community Rehabilitation And Patient Care during CMS and state inspections, most recent first.
A resident was not given their prescribed morning medications, including several critical drugs, due to a nurse's failure to administer and document them as required. The MAR lacked evidence of administration, and staff interviews confirmed the omission, with the DON substantiating the incident. The nurse assigned that day did not provide an explanation for the missed doses.
A resident was administered double doses of Synthroid for four days after a new order for an increased dose was added to the MAR without discontinuing the previous order. The error occurred when a nurse transcribed the new order but failed to remove the old one, resulting in both doses being given. The DON confirmed awareness of the incident and stated that staff are expected to review and discontinue outdated medication orders.
A resident did not receive the full number of physical therapy (PT) sessions as ordered, receiving only 15 out of 20 required sessions due to scheduling conflicts and misinterpretation of the therapy order by the rehab staff. The DON confirmed ongoing issues with missed therapy sessions.
Two residents experienced staff-to-resident abuse when a housekeeper used curse words and a threatening gesture toward one resident, and a GNA verbally abused another resident with derogatory language during care. Both incidents involved residents with significant medical and cognitive needs, and were confirmed by staff interviews and written statements, in violation of facility abuse prevention policies.
A resident experienced harm due to the facility's failure to clarify conflicting Vancomycin orders and monitor appropriate dosing. The discharge summary listed both once and twice daily dosages, but no clarification was documented. Random Vancomycin levels were obtained instead of trough levels, and high levels were not addressed by the nurse practitioners. This led to the resident being transferred to the hospital with Vancomycin toxicity and acute renal failure.
A facility failed to maintain the confidentiality of resident medical records when a laboratory log was left accessible on a nursing station countertop. The log contained sensitive information for several residents, including lab test schedules and requisition forms. A nurse confirmed the breach and moved the binder to a secure location.
The facility failed to notify the Ombudsman of resident transfers or discharges, affecting three residents who were hospitalized. Despite the requirement, there was no documentation of notification for these cases. The DON confirmed the lack of communication and acknowledged the absence of a system for notifying the Ombudsman.
The facility failed to revise care plans and conduct timely care plan meetings for residents following MDS assessments. A resident's care plan was not updated to reflect a change in wound vac status, another resident's care plan incorrectly focused on anticoagulation therapy instead of antiplatelet medication, and a third resident's care plan included interventions for a non-existent Foley catheter. Additionally, a resident reported not having a care plan meeting, and documentation confirmed a delay in scheduling it.
The facility failed to provide adequate ADL care for several residents, as evidenced by missing documentation and reports from residents about not receiving showers or grooming assistance. The DON could not provide documentation of showers being offered or completed, and residents were observed with poor hygiene and grooming.
The facility failed to maintain proper sanitation and food safety standards, with surveyors observing issues such as an overstocked freezer, incomplete temperature logs, and unlabeled food items. Wet-nesting was noted in the kitchen, and a beverage cart with expired drinks was left unattended. The DON acknowledged that procedures were not followed.
A facility failed to provide timely podiatry consultations for a resident with recurring foot infections. Despite orders for consultations, the resident did not receive timely care due to scheduling issues and an incorrect room number, which led to missed appointments. The resident had a history of atherosclerosis and diabetes, increasing the risk of infection.
The facility failed to properly inform two residents and their representatives about changes in Medicare/Medicaid coverage and potential financial liabilities. In one case, the SNF-ABN form was not sent to the resident's representative, and in another, there was no documentation of the representative's acknowledgment. The business office staff could not confirm that the necessary notifications were made.
The facility failed to notify residents and their representatives in writing about the bed hold policy during hospital transfers. This deficiency was evident for several residents, as their medical records lacked documentation of such notifications. The DON admitted that the facility did not consistently provide these notifications and acknowledged the absence of a system to ensure compliance with the policy.
A facility failed to accurately document a resident's pressure ulcers on the MDS, leading to discrepancies between the skin conditions and active diagnoses sections. The annual MDS showed an unstageable pressure ulcer not listed in diagnoses, while the quarterly MDS had conflicting entries for a stage 4 and an unstageable ulcer. These inaccuracies were confirmed by MDS Coordinators after a surveyor's review.
A facility failed to provide a resident and their representative with a summary of the baseline care plan. The resident, who lacked decision-making capacity, was readmitted after hospitalization. Despite a care plan meeting, there was no documentation that the resident or their responsible party received the care plan. The family expressed minimal communication regarding care plan changes.
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. A resident with a suprapubic catheter had no care plan for catheter care, and an inappropriate incontinence care plan was in place. Another resident had conflicting care plans for urinary incontinence and a foley catheter, which were not appropriately updated. The DON acknowledged these deficiencies.
A CMA in a LTC facility administered medications without proper labeling, violating professional standards. The CMA received unlabeled medications from a nurse, preventing verification of the five rights of medication administration. The DON confirmed that CMAs should not handle narcotics, highlighting a breach in the facility's policy.
The facility failed to follow professional standards for IV antibiotic infusions for two residents. Observations revealed unlabeled and improperly capped IV tubing, contrary to facility policy. The DON confirmed the issue and indicated staff retraining was necessary.
A surveyor observed a CMA administering unlabeled medications, including a narcotic, contrary to facility policy. The CMA claimed the medications were prepared by an RN but were not labeled, leading to a failure in ensuring accurate dispensing. The DON confirmed that CMAs should not administer narcotics, highlighting a safety concern.
The facility failed to ensure timely review and action on medication irregularity reports for three residents. One resident's Hydroxyzine prescription lacked a stop date and diagnosis, continuing beyond 14 days without physician review. Another resident's Methotrexate prescription discrepancies were noted but not corrected for 27 days. A third resident's Tylenol dosage clarification was delayed until surveyor intervention. These issues highlight lapses in communication and timely physician involvement in medication management.
A facility failed to ensure a resident's medication regimen was free from unnecessary medication by not providing an adequate indication for the use of Mirtazapine, a psychotropic medication prescribed for insomnia. Despite recommendations to reevaluate the prescription, the medication order was not changed, and the rationale for its use was not documented. The Director of Nursing acknowledged that the Medication Regimen Review report was not reviewed by the provider, and it lacked the required physician's acknowledgment of irregularity or action taken.
The facility failed to secure medication and treatment carts, with multiple instances of unattended and unlocked carts observed across different units. These carts contained medications, treatment supplies, and resident information, posing a risk to resident safety. Staff acknowledged the expectation to keep carts locked when unattended.
A facility failed to maintain complete laboratory records for a resident's vancomycin dosing. A surveyor found missing lab results in the resident's medical record, despite orders for several tests. The DON confirmed the absence of results and explained the facility's process for lab draws and documentation, revealing a lapse in ensuring lab results were completed and recorded.
The facility failed to provide or obtain dental services for two residents, despite their eligibility for on-site care through Health Direct. One resident had not received dental care since admission in 2022, and another since 2023, due to staff not signing them up for the program. The deficiency was identified during an annual survey.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in documentation regarding their decision-making capacity and life-sustaining treatment preferences. For one resident, there was a conflict between the paper and electronic records about their resuscitation wishes. Two other residents had incorrect social service assessments indicating they were responsible for their own decisions, despite certifications stating otherwise.
A facility failed to document the rationale for not administering a pneumococcal vaccine to a resident. The DON admitted that vaccine documentation in PCC was delayed due to the lack of a unit secretary. The resident did not receive the vaccine, and no declination form was signed. The IP confirmed incomplete consent forms, and the resident was not registered in ImmuNet.
The facility's kitchen walk-in freezer was found in unsafe condition with ice buildup, melting water, and missing strip curtains. The freezer's fans were not running, leading to water accumulation on the floor and wet food packages. The Director of Maintenance was unaware of the defrost mode's duration and was not certified to work on the commercial freezer.
The facility failed to maintain an effective pest control program, with surveyors observing gnats and mouse droppings in the kitchen and nursing unit. Pest control reports indicated ongoing issues with mice and roaches, and a needed door sweep was not yet installed, contributing to the deficiency.
A resident's call bell was not responded to for 14 minutes despite being illuminated and audible at the nursing station. GNAs were observed attending to another resident without an active call bell, and the Unit Secretary had informed a GNA of the need for assistance. Eventually, an RN responded, but the delay highlighted a failure in timely response expectations as stated by the DON.
Failure to Administer Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident was not administered their prescribed morning medications as ordered on June 13, 2025. Record review and interviews confirmed that the resident did not receive multiple medications, including Furosemide, Folic Acid, Ferrous Sulfate, Docusate Sodium, Amlodipine Besylate, Amiodarone HCl, Losartan Potassium, Metformin HCl, Metoprolol Succinate, Gabapentin, and Acetaminophen. The Medication Administration Record (MAR) for that date did not show documentation of medication administration, and there was no record of vital signs being obtained. An SBAR note in the medical record also indicated that the resident was not given their morning medications. Interviews with staff revealed that nurses are expected to document medication administration immediately after giving medications and to note reasons for any missed doses. The Director of Nursing confirmed that the incident was reported and substantiated, and the facility's incident report noted that the nurse assigned to the resident had a disorganized medication cart and spent significant time searching for medications. The nurse involved did not provide a statement regarding the incident.
Resident Received Double Dose of Synthroid Due to Medication Order Error
Penalty
Summary
A deficiency occurred when a resident received double doses of Synthroid (levothyroxine) due to a failure in medication order management. The resident's endocrinologist faxed a new order to increase Synthroid to 150 mcg, which was verbally verified by the in-house NP and transcribed by the assigned nurse onto the medication administration record (MAR). However, the previous order for Synthroid 137 mcg was not discontinued, resulting in the resident receiving both the old and new doses for four consecutive days. This medication error was identified during a review of the resident's medical records and confirmed by the Director of Nursing (DON), who stated that staff are expected to double-check medication orders and discontinue previous orders when new ones are received. The error led to the resident receiving double the intended dose of Synthroid, which was also associated with an abnormal lab value as noted in the complaint.
Failure to Provide Ordered Physical Therapy Services
Penalty
Summary
The facility failed to provide physical therapy (PT) services as ordered for one resident. According to the resident's physician order, PT was to be provided five times per week for four weeks, totaling 20 sessions. However, documentation showed that the resident only received 15 PT sessions during this period. The Director of Rehab stated she believed the order was for 3-5 sessions per week rather than five, and attributed the missed sessions to scheduling conflicts. The Director of Nursing acknowledged ongoing issues with residents missing therapy sessions.
Staff-to-Resident Verbal and Non-Verbal Abuse
Penalty
Summary
The facility failed to maintain an environment free from staff-to-resident verbal and non-verbal abuse for two residents. In the first incident, a housekeeper used curse words and made a threatening gesture by raising a middle finger toward a resident in the resident's bedroom. The resident involved had diagnoses including congestive heart failure, pulmonary hypertension, atrial fibrillation, morbid obesity, hypertensive heart disease with heart failure, difficulty walking, muscle weakness, and adjustment disorder with anxiety. The resident was assessed by nursing and social services following the incident, and no ill effects were noted at that time. In the second incident, a general nursing assistant verbally abused another resident and used derogatory comments while providing care. The resident had cognitive communication deficits, congestive heart failure, chronic kidney disease, and was documented as cognitively impaired with a BIMS score of 6/15. The resident was dependent on staff for emotional, intellectual, physical, and social needs. During care, the nursing assistant used profane language, including telling the resident to "kiss my ass" and "fuck you," and refused to assist with breakfast requests. Multiple staff statements and interviews confirmed the use of abusive language and inappropriate conduct toward the resident. Both incidents were reported by staff and confirmed through interviews and written statements. The facility's policies prohibit all forms of abuse, including verbal and mental abuse, and require immediate reporting of suspected abuse. The actions of the housekeeper and the nursing assistant were in direct violation of these policies, resulting in the documented deficiencies.
Failure to Clarify Medication Orders and Monitor Vancomycin Levels
Penalty
Summary
The facility failed to clarify a medication discrepancy on the hospital discharge summary for a resident who was prescribed Vancomycin for bacteremia. The discharge summary contained conflicting orders for Vancomycin administration, listing both once daily and twice daily dosages. The facility did not document any clarification of these orders, leading to the administration of Vancomycin twice daily without proper verification. This discrepancy was not addressed by the nursing staff or the nurse practitioner, resulting in the resident receiving an incorrect dosage. Additionally, the facility did not appropriately monitor the Vancomycin dosing by ordering the correct laboratory tests. Random Vancomycin levels were obtained instead of the recommended trough levels, which are necessary for accurate dosing. Despite obtaining high random Vancomycin levels, no action was taken by the nurse practitioners who reviewed the results. The resident's Vancomycin levels continued to rise, reaching toxic levels, which were not addressed until the resident was transferred back to the hospital with Vancomycin toxicity and acute renal failure. The facility's process for handling laboratory results and medication orders was inadequate. The laboratory results were not consistently flagged for review, and there was a lack of communication between the facility and the pharmacy regarding the Vancomycin levels. The medical director and nurse practitioners did not ensure that the correct laboratory tests were ordered or that abnormal results were acted upon. This failure in the facility's processes led to harm to the resident, who was eventually diagnosed with acute renal failure due to Vancomycin toxicity.
Confidentiality Breach of Resident Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of resident medical records, as evidenced by the accessibility of a laboratory log. During an initial tour of the nursing unit, surveyors observed a black binder on the countertop at the nursing station. This binder contained a laboratory log with the names and laboratory information of seven residents. The log included documents such as resident lab test logs, lists of residents scheduled for specific labs, Clinical Laboratory Outpatient Requisition forms, and lab and diagnostic records from Point Click Care (PCC). A Registered Nurse confirmed that the binder was the resident's laboratory log and acknowledged that it should have been stored behind the nursing station, away from public access. The nurse then removed the binder from the countertop and placed it behind the nursing station.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers or discharges, as required. This deficiency was identified during a survey that reviewed the cases of five residents who were hospitalized. Specifically, the facility did not notify the Ombudsman about the hospitalizations of three residents. Resident #17 was transferred to the hospital on March 15, 2024, but there was no documentation of Ombudsman notification. The Director of Nursing (DON) confirmed the lack of communication after consulting with the Social Worker and business office. Similarly, Resident #90 was transferred to the hospital in March 2024 for treatment of sepsis, but again, there was no documentation of Ombudsman notification. The DON was unable to provide evidence of such notification. Additionally, Resident #73 was transferred to the hospital in October 2023, and while the resident's representative was informed, there was no record of Ombudsman notification. The DON acknowledged the absence of a system for notifying the Ombudsman and indicated that the responsibility would be assigned to the Guest Services Director moving forward.
Deficiencies in Care Plan Revisions and Meetings
Penalty
Summary
The facility failed to revise care plans and hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This deficiency was evident in several cases. Resident #42 had a physician order to hold a wound vac due to active bleeding, but the care plan was not updated to reflect this change. Resident #80's care plan incorrectly focused on anticoagulation therapy, despite the resident being prescribed an antiplatelet medication, Clopidogrel, and Aspirin, with no anticoagulant medication ordered. Additionally, Resident #75's care plan included interventions for a Foley catheter that the resident did not have, and there was no documentation of a resolved pressure ulcer on the care plan. Furthermore, Resident #322 reported never having a care plan meeting. The medical record review confirmed that a comprehensive care plan was not completed following the baseline care plan. The Director of Nursing acknowledged the expectation to have a care plan meeting within 7 days after completing the comprehensive assessment, but documentation of such a meeting was not found. The Social Services Director and Staff #51 confirmed the delay in scheduling the care plan meeting for Resident #322.
Deficiencies in ADL Care and Documentation
Penalty
Summary
The facility staff failed to provide adequate activities of daily living (ADL) care in accordance with the care plans for several residents. Resident #322 reported never being offered a shower, despite care plans indicating the importance of choosing between different bathing options. The shower logbook lacked documentation for the entire month of April, with only two entries dated 4/20/24 and the next dated 3/18/24. The Director of Nursing (DON) could not provide documentation that a shower was offered or completed for Resident #322, with only bed baths recorded. Resident #97 also reported never having been in the shower since admission, only being offered a pan of water for bathing. Similar to Resident #322, the shower logbook lacked documentation, and the DON could not provide evidence of showers being offered or completed. Resident #321 was observed with a film on their teeth, and the care plan indicated a need for assistance with ADLs due to recent illness and limited mobility. Again, the DON could not provide documentation of showers being offered or completed, with only bed baths recorded. Resident #41 was observed with poor grooming, wearing a food-stained gown, and having crusty eyes and leftover food on their face. The resident stated they did not receive morning grooming assistance, and the Unit Manager confirmed the failure to provide such assistance. Resident #80 was observed with a black substance under their fingernails over multiple days, and the care plan indicated dependency on staff for personal hygiene and bathing. The DON stated that nail care should be performed during showers or bed baths, but there was no documentation of refusal or care provided.
Sanitation and Food Safety Deficiencies in Kitchen and Nursing Units
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen and on nursing units, as observed during an annual survey. In the kitchen, surveyors noted several deficiencies, including a missing dish machine log, an overstocked and disorganized walk-in freezer with food items on the floor, and the presence of gnats. Additionally, there was ice and sediment on the freezer fan, ice on food items, and an open loaf of bread. The kitchen floor was littered with crumbs and stains, and there was wet-nesting of serving pans, which is against FDA guidelines. The surveyors also found a broken hand sink and trash piled up at the kitchen entrance. On the nursing units, the surveyors observed incomplete temperature logs and dirty nourishment refrigerators with spilled substances and unlabeled food items. The Director of Nursing acknowledged that the expectation was for daily temperature checks, cleanliness, and proper labeling of food items. The surveyors also noted expired and unlabeled food items in the dry storage area and wet-nesting on food preparation pans. During meal delivery, wet-nesting was observed on plate lids used to cover residents' food. A beverage cart was left unattended in the hallway with expired beverages, lacking proper temperature control. The Unit Manager and Kitchen Serving Staff confirmed that expired beverages should not have been served, and the cart should not have been left in the hallway. The Director of Nursing agreed that the correct procedures were not followed, leading to these deficiencies.
Failure to Provide Timely Podiatry Consultations
Penalty
Summary
The facility failed to ensure timely podiatry consultations for a resident with recurring foot infections. On July 28, 2022, a provider noted erythema in the resident's right first toe and recommended a podiatry consult, which was not scheduled by the facility. The resident's medical records showed a physician's order for a podiatry consult to be scheduled by August 2, 2022, but there was no evidence that this consult occurred. Subsequent medical records revealed that the resident continued to experience issues with the right great toe, including an open wound and black crust near the nail, prompting another podiatry consult order on October 7, 2022. A podiatry note from October 1, 2022, indicated the resident had generalized atherosclerosis and an ingrown toenail, which was treated. The note also highlighted the resident's increased risk of infection due to co-morbidities such as Type 2 Diabetes Mellitus and peripheral circulatory disorders. The Director of Nursing (DON) later stated that the resident was not in the facility at the time of the scheduled podiatry consults. However, documentation from the Health Drive Podiatry group indicated that the resident was unavailable due to an incorrect room number, not because the resident was absent from the facility. This discrepancy contributed to the failure to provide timely podiatry care, as the resident's location could not be verified, leading to missed consultations.
Failure to Notify Residents of Coverage Changes
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were properly informed of changes in Medicare/Medicaid coverage and potential financial liabilities for services not covered. This deficiency was identified during a review of the Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) forms for two residents. In the case of one resident, the SNF-ABN form was not sent to the resident's representative as requested, and there was no documentation of the representative's acknowledgment or refusal to sign the form. The business office staff was unable to provide a clear explanation for this oversight. For another resident, the SNF-ABN form lacked any signature or acknowledgment, and there was no evidence that the form was communicated to the resident's representative. Although an email was sent regarding the Notice of Medicare Non-Coverage (NOMNC), it did not include the SNF-ABN form. The business office manager admitted that there was no documentation to confirm that the representative was informed about the SNF-ABN form, highlighting a failure in the facility's process to ensure proper notification and acknowledgment of coverage changes.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to have an effective system in place to ensure that residents and their representatives were notified in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified during the annual survey for five residents who were hospitalized. The surveyor found no documentation of bed hold notifications in the medical records of these residents. The Director of Nursing (DON) admitted that the facility almost always did not provide these notifications and acknowledged that the process was a shared responsibility that needed improvement. Specific instances included the lack of bed hold notifications for residents who were recently hospitalized. For example, Resident #6 and Resident #43 had no bed hold notices in their records, and the DON confirmed the absence of such documentation. Similarly, Resident #17, Resident #90, and Resident #73 also lacked written notifications of the bed hold policy, despite being transferred to the hospital. The DON explained that the expectation was for nursing staff to provide the bed hold policy at the time of transfer, with the business office following up the next day. However, there was no system in place to ensure this process was completed, and the facility's policy requiring written notice to be maintained in the medical record was not followed.
Inaccurate MDS Documentation for Pressure Ulcers
Penalty
Summary
The facility failed to accurately document a resident assessment on the Minimum Data Set (MDS) for a resident, leading to discrepancies in the recorded information. The MDS is a critical tool used for assessing the health status of residents in long-term care facilities, and it is federally mandated for clinical assessments. In this case, the surveyor found that the annual MDS for the resident indicated an unstageable pressure ulcer in the skin conditions section, but this was not reflected in the active diagnoses section. Similarly, the quarterly MDS showed a stage 4 pressure ulcer in the skin conditions section, but the active diagnoses section listed both an unstageable pressure ulcer of the sacral region and a stage 4 pressure ulcer of an unspecified part of the back. The discrepancies were identified during a review of the resident's medical records and confirmed through interviews with the MDS Coordinators. The surveyor explained the inconsistencies to the coordinators, who acknowledged the inaccuracies in the documentation. The failure to accurately document the resident's condition on the MDS assessments highlights a deficiency in the facility's assessment and documentation processes, as evidenced by the inaccurate coding of the resident's pressure ulcers.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility staff failed to provide a resident and their representative with a summary of the baseline care plan, which was identified during an annual survey. The deficiency was evident for one resident who had been admitted to the facility in early January 2024 and was recently readmitted after a hospitalization. The resident's medical record indicated that two providers certified the resident lacked adequate decision-making capacity for health care decisions. Despite a care plan meeting being documented on March 25, 2024, after the resident's readmission, there was no documentation indicating that the resident or their responsible party received a copy of the baseline care plan. The resident's family, including the son who is the Power of Attorney, expressed minimal communication regarding changes to the care plan during a phone interview with the surveyor.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in their care. Resident #17, who had a suprapubic catheter, was hospitalized due to an infection after the catheter was changed. Upon readmission to the facility, there was no care plan addressing the care of the suprapubic catheter, and an inappropriate incontinence care plan was in place instead. The Director of Nursing acknowledged that a care plan for the suprapubic catheter should have been created and that the existing incontinence care plan was not suitable for a resident with an indwelling catheter. Similarly, Resident #103 was admitted with a history of benign prostatic hyperplasia and required assistance with personal care. Initially, a care plan was created for urinary incontinence, but after a foley catheter was placed due to urinary retention, a new care plan was added. However, the original incontinence care plan was not removed, leading to conflicting care plans. The Director of Nursing confirmed that maintaining both care plans was inappropriate and that the incontinence care plan should have been removed once the foley catheter was in place.
Failure to Adhere to Medication Administration Standards
Penalty
Summary
The facility failed to adhere to professional standards during medication administration, as observed by a surveyor. A Certified Medication Assistant (CMA), identified as Staff #37, was seen administering medications without proper labeling, which is a violation of the facility's policy. The CMA was observed taking medications from a cart, including a white pill believed to be Tramadol, without any label or direction on the medication cup. The CMA claimed to have received the medication from a Registered Nurse, Staff #2, who had not labeled the medications due to a malfunctioning marker. This lack of labeling prevented the CMA from verifying the five rights of medication administration, which include the right patient, drug, route, time, and dose. Further observations revealed that the CMA was given three unlabeled medications by Staff #2 to administer to different residents. The Director of Nursing (DON) confirmed that CMAs are not permitted to administer narcotic medications and acknowledged the safety concern posed by the unlabeled medications. The facility's policy mandates that medications should not be administered if the label is missing or illegible, and controlled substances should only be accessible to licensed nursing staff. The surveyor's findings highlighted a breach in the facility's medication administration policy, specifically regarding the handling and labeling of medications.
Failure to Properly Label and Cap IV Tubing
Penalty
Summary
The facility failed to adhere to professional standards of practice during the administration of intermittent intravenous (IV) antibiotic infusions for two residents. During the recertification survey, it was observed that the IV tubing for Resident #43 was not labeled with the date and was improperly inserted into an upper tubing port. The Director of Nursing (DON) confirmed that the facility's procedure required the IV tubing to be labeled, dated, and capped when not in use. The DON acknowledged the issue and indicated that staff would be retrained in the proper procedures. Similarly, for Resident #376, the surveyor noted that the IV tubing was not labeled or capped, and the end was connected to an upper port. RN #30, responsible for the resident's care, confirmed the tubing was not labeled or capped and stated that she would dispose of unlabeled tubing and replace it with new tubing. The facility's policy on the administration of intermittent infusions requires that administration sets used for more than one dose in a 24-hour period be changed every 24 hours, and that medication/solution containers and administration sets be labeled with the date, time, and nurse's initials, with a new sterile end cap placed on the end of the administration set when infusion is completed.
Medication Administration Deficiency Due to Unlabeled Medications
Penalty
Summary
The facility failed to administer medication according to procedures that ensure accurate dispensing, as observed by a surveyor. A Certified Medication Assistant (CMA) was seen administering medications without proper labeling, which is against the facility's policy. The CMA was observed taking medications from a cart, including a white pill that was not labeled, and claimed it was Tramadol, given by a Registered Nurse (RN) earlier. The CMA administered these medications to a resident without verifying the medication's identity due to the lack of labeling. Additionally, the CMA was found with other unlabeled medication cups, which she claimed were prepared by the RN, but she was unsure why they were not labeled that day. The Director of Nursing (DON) confirmed that CMAs are not permitted to administer narcotic medications, and the unlabeled medications posed a safety concern. The surveyor's review of the facility's policy indicated that medications should not be administered if the label is missing or illegible, and controlled substances should only be accessible to licensed nursing staff. The surveyor also confirmed that one of the unlabeled medications was Oxycontin, a narcotic pain medication, which was not supposed to be administered by the CMA. The resident involved was assessed and found to be at her baseline with no concerns regarding her morning medications.
Failure to Address Medication Irregularities in a Timely Manner
Penalty
Summary
The facility failed to ensure that medication irregularity reports were reviewed by the primary care physician and that recommendations were addressed in a timely manner for three residents. For Resident #103, a Medication Regimen Review (MRR) conducted on April 1, 2024, identified an irregularity with the prescription of Hydroxyzine, which lacked a stop date and a specific diagnosis. Despite the irregularity being noted, the report was not reviewed by the provider, and no action was taken to address the issue, resulting in the medication order continuing beyond the recommended 14 days. For Resident #90, the MRR identified discrepancies in the Methotrexate prescription, which was written differently from the hospital transfer summary. The report recommended a dose adjustment and clarification of the medication's indication. Although a provider noted the issue on January 5, 2024, the recommendation was not implemented until 27 days later, with no documented rationale for the delay or for not following the initial pharmacy recommendations. Resident #42's MRR from March 20, 2024, included a recommendation to clarify the dosage of Tylenol Extra Strength tablets. However, the facility failed to notify the physician of this recommendation until prompted by the surveyor's inquiry. This oversight was confirmed by the Director of Nursing, who acknowledged that the physician had not been informed of the pharmacist's recommendation until after the surveyor's investigation.
Failure to Ensure Appropriate Use of Psychotropic Medication
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by not providing an adequate indication for the use of a psychotropic medication. The resident in question had a medical history that included cerebral infarction, abnormal gait, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The surveyor found that Mirtazapine, a psychotropic medication, was prescribed for insomnia, which is not an approved indication for its use. This was noted during a review of the resident's Medication Regimen Review (MRR) and Medication Administration Record (MAR). The Director of Nursing (DON) acknowledged that the MRR report, which recommended reevaluation of the Mirtazapine prescription, was not reviewed by the provider. The report lacked the required physician's acknowledgment of irregularity or any action taken to address it. Despite the recommendation to reevaluate or provide clinical rationale for the use of Mirtazapine, the medication order was not changed, and the rationale for its administration was not documented. The medication continued to be administered until the resident was discharged.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain a secure system for medication and treatment carts, as observed during random tours. On the 300-nursing unit, a treatment cart was found unattended and unlocked, containing scissors, ointments, creams labeled with resident names, dressings, and bandages. The assigned LPN was at the other end of the hallway, and upon request, returned to the cart to lock it. On the 400-nursing unit, a medication cart was also found unattended and unlocked, with medications labeled with resident names and room numbers, and a narcotic book with resident details. An insulin pen meant to be refrigerated was found in the cart, and the responsible LPN acknowledged the cart should be locked when unattended. On the 200 Unit, another medication cart was observed unattended and unlocked, with multiple bottles of medications and punch cards with resident doses. The responsible RN admitted to forgetting to lock the cart despite recent training on medication storage. The Director of Nursing was informed of the unlocked cart, acknowledging the concern. These observations indicate a pattern of unsecured medication and treatment carts across different units, posing a risk to resident safety.
Failure to Maintain Complete Laboratory Records
Penalty
Summary
The facility failed to maintain complete laboratory records in the medical record of a resident, specifically for vancomycin dosing. On a specified date, a surveyor reviewed the medical record of a resident and found that an order for a lab blood draw was placed by the Medical Director. The order included several tests, such as a complete blood count and vancomycin trough, to be conducted on a specific date. An additional lab order was written for further tests to be conducted weekly. However, upon review, the surveyor found that the lab results from the initial order were missing from the resident's medical record. During an interview, the Director of Nursing (DON) confirmed that the results from one of the lab draws were not in the resident's medical record and that the labs from the initial order appeared not to have been completed. The DON explained the facility's process for obtaining lab draws and the expected procedure for recording lab results. Despite other residents having their labs drawn on the same day, the resident in question did not have any lab results recorded, indicating a failure in the facility's process for ensuring lab results are completed and documented in the medical record.
Failure to Provide Dental Services
Penalty
Summary
The facility staff failed to promptly provide or obtain dental services for two residents, leading to a deficiency identified during an annual survey. Resident #74, who was admitted with diagnoses including cardiac arrhythmia, dementia, and anemia, had not received any dental visits since admission in June 2022. Despite being eligible for dental care through Health Direct since February 2023, the staff had not signed the resident up for these services. The Unit Manager confirmed the lack of dental visits and stated that a referral had only recently been completed, with the scheduling of a visit still pending. Similarly, Resident #88, admitted with conditions such as heel decubiti, Parkinson's, dementia, and chronic heart failure, had not received any dental visits since admission in September 2023. Although the resident was eligible for Health Direct services since November 2023, the staff failed to activate the resident for the program. The resident's family had inquired about the overdue dental visit, and the Unit Manager acknowledged the oversight, having only made a dental referral recently. The Director of Nursing and the Administrator confirmed the partnership with Health Direct but admitted that the services were not fully utilized, resulting in the deficiency.
Inaccurate Medical Record Documentation for Residents
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards, as evidenced by incomplete and inaccurate documentation for three residents. For Resident #322, discrepancies were found between the paper medical chart and the electronic medical record regarding the resident's wishes for life-sustaining treatments. The paper chart contained a MOLST form indicating the resident wished for cardiopulmonary resuscitation, while a progress note in the electronic record stated a new MOLST form was completed, reflecting the resident's desire to be a full code. However, the updated MOLST form was not provided to the surveyor. For Resident #103, there was a contradiction between the social service assessment and the certifications by two physicians regarding the resident's decision-making capacity. The social service assessment incorrectly indicated that the resident was responsible for their own decisions, despite certifications stating the resident lacked decision-making capacity. Similarly, for Resident #4, the social service assessment inaccurately marked the resident as responsible for their own decisions, although certifications confirmed the resident lacked decision-making capacity. These errors in documentation highlight the facility's failure to ensure accurate and complete medical records.
Failure to Document Pneumococcal Vaccination Rationale
Penalty
Summary
The facility failed to document the rationale for the non-administration of the pneumococcal vaccination for one resident during an annual survey. The Director of Nursing (DON) acknowledged that the documentation of vaccines in the Point Click Care (PCC) system was not up to date, particularly in the 200 Hall, due to the absence of a unit secretary. The process outlined by the DON indicated that the unit secretary is responsible for inputting vaccine information into PCC after administration, while floor nurses assess and administer vaccines upon admission when available from the pharmacy. During the survey, it was discovered that the resident had not been administered the pneumococcal vaccine, and no declination form was signed. The Infection Preventionist (IP) confirmed that the consent forms were incomplete and still on the resident's chart. The facility checked the ImmuNet system and found that the resident was not registered. The deficiency was identified as a failure to follow the process of obtaining consents on admission and ensuring the administration of the vaccine when available.
Unsafe Conditions in Kitchen Walk-In Freezer
Penalty
Summary
The facility failed to maintain the kitchen walk-in freezer in a safe operating condition. During an initial tour, it was observed that the freezer was filled with a cloud-like mist, making visibility difficult. There were small mounds of ice covering the ceiling, and ice clumps and icicles were present on the two circular fans of the main unit. Ice was also found on boxes of food, shelving, and food packages. Additionally, the strip curtains were missing from both the freezer and refrigerator. Upon revisiting the freezer, it was noted that the fans were not running, the ice on the fans was melting, and water was accumulating on the floor. The ice buildup on the ceiling had melted, resulting in wet boxes and food on the shelves. Water was also visible inside the light fixture attached to the ceiling. The Director of Maintenance stated that the freezer was in defrost mode but was unaware of the duration or frequency of this mode. It was also discovered that the Director of Maintenance was not certified to work on the commercial freezer.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of rodents and insects in various areas. During an initial tour of the kitchen, surveyors observed gnats flying around the bread cart and at the entrance of the kitchen. Further observations in the Nursing Unit 300 revealed gnats and mouse traps in a resident's room. A follow-up tour of the kitchen uncovered a significant amount of mouse droppings on the floor in the dry storage room, as well as an opening at the bottom of the exit doors in the service area, which could facilitate pest entry. The review of pest control reports from January to April 2024 indicated ongoing pest issues, including mice activity in various areas and treatment for roaches in the kitchen. The reports noted the need for a door sweep on the exit door, which had been communicated to maintenance. Despite these observations and reports, the facility had not effectively addressed the pest control issues, leading to the continued presence of pests in the facility.
Failure to Respond to Call Bell in a Timely Manner
Penalty
Summary
The facility failed to ensure timely response to call bells, as observed in the case of Resident #80. On the morning of 4/18/24, Resident #80 reported that their call bell was not functioning properly, although maintenance had worked on it. A surveyor confirmed the call bell was illuminated after pressing it, yet it remained unanswered for 14 minutes. During this time, Geriatric Nursing Assistants (GNAs) #13 and #14 were observed attending to another resident who did not have an active call bell. The Unit Secretary acknowledged hearing the call bell alarm and informed GNA #13, who did not respond. Eventually, Registered Nurse (RN) #2 responded to the call bell, turning it off. The Director of Nursing stated that staff are expected to respond to call bells promptly, indicating a lapse in protocol adherence.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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