Fayette Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baltimore, Maryland.
- Location
- 1217 West Fayette Street, Baltimore, Maryland 21223
- CMS Provider Number
- 215183
- Inspections on file
- 18
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Fayette Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
The facility staff failed to ensure that residents received showers at least twice a week, as required. Multiple residents reported not receiving showers, and clinical records confirmed the lack of showers. Staff interviews revealed misunderstandings and lack of documentation regarding residents' shower schedules and refusals.
The facility failed to ensure the accuracy of MOLST and maintain proper advance directives for several residents. For example, one resident's MOLST form contained errors, and another resident had no documentation of a MOLST or advance directive despite residing at the facility for over 11 months. The Social Worker admitted to not routinely asking residents if they wanted to complete an advance directive.
The facility failed to hold timely care plan meetings with an interdisciplinary team for three residents, as required by the MDS assessment schedule. One resident reported never being invited to a care plan meeting, another had no documented meetings since 2020, and a third had not had a meeting since admission.
The facility failed to safeguard resident-identifiable information and maintain accurate medical records. An unattended medication cart displayed a resident's medication profile, and several instances of inaccurate documentation were found, including incorrect notes about dialysis, dressing changes, and medications. Additionally, a resident did not receive prescribed medications, yet the LPN documented that they were administered.
The facility failed to sanitize medical equipment between residents and did not maintain gown availability for Enhanced Barrier Precautions (EBP). A CMA used a blood pressure monitor on two residents without sanitizing it, and rooms with EBP signs lacked gowns. Staff interviews revealed a lack of awareness and proper procedure for obtaining gowns.
The facility failed to notify residents and their representatives in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified for four residents, with medical records lacking documentation and staff interviews confirming the policy was not provided as required.
The facility failed to accurately document MDS assessments for four residents, including errors in recording dialysis dependence, tobacco use, mental health diagnoses, and assistance levels for a resident with bilateral above-knee amputations. These inaccuracies were confirmed through medical record reviews and staff interviews.
The facility failed to provide proper wound care for four residents, resulting in inconsistent and inaccurate documentation, lack of supervision, and missing wound care orders. The staff acknowledged the deficiencies but did not provide additional information or corrective actions.
The facility staff failed to ensure the privacy and confidentiality of residents' personal and medical information. A discharge summary and PASRR form for one resident were incorrectly placed in another resident's clinical record. The Administrator confirmed the error during an interview.
The facility failed to protect residents from verbal abuse in two separate incidents. In one case, an RN used profane language and was dismissive towards a resident. In another case, a video of a staff member verbally abusing a resident was circulated online, leading to the staff member's termination.
The facility staff failed to ensure resident dignity as evidenced by staff not wearing name tags and using personal cell phones during resident care. One GNA and one RN were observed without name tags, and another GNA was seen using a personal cell phone while assisting a resident with lunch.
The facility failed to ensure that a resident's personal property was not lost. Despite the resident reporting missing clothes to multiple staff members, no grievance forms were found, and the personal inventory sheet was missing from the resident's chart. The Housekeeping Supervisor suggested the clothes might have been mistakenly donated, and the NHA only completed a grievance form after the surveyor's intervention.
The facility failed to report a reasonable suspicion of abuse resulting in serious bodily injury within the required 2-hour timeframe. A resident complained of right hip pain and mentioned a fall three days prior. An x-ray confirmed a hip fracture, and the resident was transferred for urgent surgery. The initial self-report was delayed by 2 days and 7 hours, violating reporting requirements.
The facility failed to provide written notice with the reason for transfer to residents and failed to notify the Ombudsman of residents that transferred. This deficiency was identified in three residents who were hospitalized, with staff providing only verbal notifications and no written notices.
The facility failed to develop and provide a baseline care plan for two newly admitted residents within 48 hours of their admission. For one resident, the nursing evaluation did not indicate that care planning was discussed or that the resident received a summary, and it lacked documentation of planned therapy services, goals, and a summary of medications with dietary instructions. The Nursing Home Administrator did not provide additional information by the time of the surveyor's exit.
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. One resident's smoking habits were not addressed in the care plan, another resident's discharge planning was overlooked, and a third resident's incontinence was not managed according to their care plan. The Nursing Home Administrator acknowledged these deficiencies during the surveyors' visit.
The facility staff failed to ensure that a resident's toenails were cut, resulting in a long toenail on the big toe of the right foot. The resident reported that no one had cut the toenails even after dressings were changed, and the issue persisted for several days.
The facility failed to provide an activities program that meets the interests and needs of residents based on their comprehensive assessments and care plans. Two residents expressed preferences for specific activities, but the documented activities were minimal and did not align with their stated interests. The Administrator and Regional Clinical Director acknowledged the deficiency when shown the activity logs.
The facility failed to maintain a medication error rate of 5% or less. A CMA did not administer Vitamin D to a resident as ordered and incorrectly documented it as given. Additionally, the CMA administered Levothyroxine to another resident after breakfast, contrary to the order specifying it should be given before breakfast. The error rate was found to be 8%.
The facility failed to secure medication and treatment carts, as observed during random tours. Unlocked carts containing medications and medical supplies were found on the 1st and 3rd floors. Staff confirmed the carts should have been locked when unattended.
The facility staff failed to assist a resident in making necessary appointments for dental care or treatment. Despite a dentist's recommendation for extractions, no extractions were performed during subsequent visits, and no further appointments were scheduled. The resident, who had only three teeth left and reported gum pain, did not receive the necessary dental care.
The facility failed to employ an LPN in accordance with Maryland State laws. The LPN had an active Virginia license but lacked necessary documentation and currently resides in Maryland. The NHA confirmed awareness of the licensing requirement and informed the LPN to apply for a Maryland license.
The facility failed to ensure that residents' bed mattresses were properly secured to the bed frames, leading to safety concerns. This deficiency was observed in two residents, one with a history of falling and another with bilateral amputation, both requiring assistance with transfers and moving in bed. The Maintenance Director acknowledged the issue but failed to resolve it promptly.
The facility failed to maintain an effective pest control program, as evidenced by multiple gnats swarming in a resident's room. The DON confirmed the infestation and reported it to the NHA, who was initially unaware of the issue. Pest logs showed prior extermination treatments for gnats.
The facility failed to ensure required in-service training for nurse aide staff was completed, specifically for a Geriatric Nursing Assistant hired in October 2023. Despite using computer-based training programs and messaging systems, the facility could not provide documentation of the necessary training, revealing a deficiency in monitoring and record-keeping.
The facility failed to inform a resident's representative of changes to the care plan, leading to confusion about who should be contacted for decisions. Despite evaluations indicating the resident's incapacity, the social history assessment incorrectly listed the resident as having decision-making capacity, resulting in inconsistent notifications to the resident and their ex-spouse.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility staff failed to ensure that residents received showers at least twice a week, as required. This deficiency was identified through interviews with residents and staff, as well as clinical record reviews. Resident #81 reported not having had a shower in three days and only receiving bed baths in February and March. The Unit Manager acknowledged the issue but had not taken action. Resident #111 also reported not receiving showers, and although a nurse claimed the resident was scheduled for showers, there was no documentation to support this. Resident #116 stated they had only one shower in the last 30 days, and their clinical records confirmed the lack of showers. The Unit Manager incorrectly assumed the resident was independent and chose not to shower, despite no documentation of refusal in the clinical records. Resident #28 reported receiving only two showers since admission a year ago. Clinical records showed the resident received bed baths but not showers, except for one tub bath. The resident's assigned GNA confirmed the lack of routine showers, and there was no documentation of the resident refusing showers. The Nursing Home Administrator and Regional Director of Operations confirmed that residents should receive showers twice a week and that GNAs are expected to document this on the ADL flow sheet. However, this expectation was not met, leading to the deficiency.
Failure to Ensure Accuracy of MOLST and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) and to maintain proper advance directives in the residents' medical records. This deficiency was evident for seven out of nine residents reviewed. For instance, Resident #27's legal contact person could not recall if a completed MOLST or advance directive was provided upon admission. The facility's internal face sheet section was used instead, leading to an error in the MOLST form, which incorrectly stated that the resident was mentally competent and had given informed consent. Additionally, the Social Worker admitted that the MOLST and advance directive were not obtained during the admission period, and a blank form was only sent out after the surveyor's intervention. Similarly, Resident #64 had resided at the facility for over 11 months without proper documentation of a MOLST or advance directive. The Social Worker confirmed that these documents were not completed and relied on the internal face sheet section instead. Resident #61's clinical record also lacked an advance directive, and the Social Worker admitted that they do not routinely ask residents if they want to complete one. Resident #111's record showed no advance directive, and although the resident was aware of it, there was no evidence that the facility staff offered assistance in its completion. These findings were communicated to the Administrator and the Regional Director of Clinical Operations, who acknowledged the issues but did not provide immediate corrective actions.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This deficiency was evident for three residents. Resident #97 reported never being invited to a care plan meeting. The Social Worker Assistant, responsible for planning these meetings, admitted to not being up-to-date on conducting care plan meetings and could not provide any progress notes for Resident #97's care plan meetings. The Social Worker overseeing the assistant was unaware of the backlog and confirmed the deficiency upon review. Resident #33 did not recall having a care plan meeting, and record reviews confirmed that no care plan meetings had been documented since January 2022. The Social Worker confirmed that the last care plan meeting for this resident was in 2020. Resident #81 also reported not having had a care plan meeting since admission and had not seen the Social Worker. The requested care plan attendance sheets were not provided before the exit conference, further indicating a lapse in the facility's care planning process.
Failure to Safeguard Resident Information and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain medical records in accordance with acceptable professional standards and practices by not safeguarding resident-identifiable information and keeping accurate documentation. An unattended medication cart with a computer displaying a resident's medication profile was observed, exposing sensitive information to the public. The involved staff acknowledged the issue but did not take appropriate measures to prevent it from happening again. Inaccurate documentation was also found in the medical records of several residents. One resident's record incorrectly noted that they were escorted to dialysis, which the interim Director of Nursing confirmed was an error. Another resident's Treatment Administration Record showed a dressing change as completed when it had not been done, and the resident confirmed that they no longer had a toe wound. Additionally, another resident's progress notes inaccurately documented the presence of medical devices and medications, which staff attributed to errors in the electronic medical record system. Furthermore, a resident did not receive four prescribed medications because they were not available in the medication cart, yet the LPN documented that the medications were administered. The LPN later admitted that the medications were not obtained, and the Nursing Home Administrator and Director of Nursing were informed of the discrepancy. The medications were eventually located and administered, but the initial failure to provide them and the inaccurate documentation were significant issues.
Infection Control and PPE Availability Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitization of medical equipment between residents and did not maintain the availability of gowns for Enhanced Barrier Precautions (EBP). During a medication administration observation, a Certified Medication Aide (CMA) used a blood pressure monitor with a wrist cuff on two different residents without sanitizing the equipment between uses. The CMA acknowledged the failure to sanitize the equipment and stated that the facility's expectations were to sanitize all shared medical equipment after each use and between each resident. The Director of Nursing (DON) confirmed that it is expected of all nursing staff to sanitize medical equipment between residents with sanitizing wipes. Additionally, the facility did not ensure that gowns were available for staff use as required by EBP signage posted on certain rooms. Observations revealed that rooms with EBP signs did not have gowns stocked in the wall caddies or on a cart outside the rooms. Interviews with staff indicated a lack of awareness and proper procedure for obtaining gowns. The Unit Manager, Regional Director of Clinical Operations, and Infection Control Nurse were shown the deficiency, and supplies were subsequently obtained and stocked. The Infection Control Nurse confirmed that staff are expected to wear gloves and gowns for direct resident care under EBP, and the DON acknowledged the issue with gown availability and stated that efforts were being made to educate staff and maintain supplies.
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 are notified in writing of the bed hold policy upon transfer to the hospital. This deficiency was identified for four residents during the annual survey. For Resident #16, there was no documentation that the bed hold was offered upon transfer to the hospital, and interviews with LPNs revealed that they did not offer or document the bed hold policy. The Nursing Home Administrator confirmed the expectation for staff to offer and document bed holds but could not locate any evidence of this for Resident #16's transfer on 3/6/24. For Resident #63, the medical record review showed no documentation that the bed hold policy was provided upon transfer to the hospital. Interviews with RN #4 and the Director of Nursing revealed that the bed hold policy is reviewed only during the admissions process and not provided in writing at the time of transfer. The Social Worker and Administrator confirmed that the nursing staff should offer a written copy of the bed hold policy when the resident is transferred out of the facility, but this was not done for Resident #63. Similarly, Resident #109's medical record lacked documentation of the bed hold policy being provided upon transfer to the hospital. Interviews with RN #4, the Director of Nursing, and the Social Worker indicated that the bed hold policy is not reviewed or provided in writing at the time of transfer. The Administrator confirmed that the policy should be offered in writing but was not done for Resident #109. For Resident #117, there was no documentation that the bed hold policy was provided at the time of transfer to the hospital, and the Administrator and Regional Clinical Director did not dispute the findings or provide any evidence of notification.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document resident assessments on the Minimum Data Set (MDS) for four out of six residents reviewed. Resident #16 had a diagnosis of End Stage Renal Disease and was dependent on dialysis, but the MDS assessment did not indicate that the resident received dialysis. Resident #28's MDS assessment incorrectly documented that the resident did not use tobacco, despite multiple smoking assessments indicating nicotine use. Resident #24's MDS assessment did not reflect active diagnoses of depression and anxiety disorder, although the resident was receiving antianxiety and antidepressant medications. Resident #13, who had bilateral above-knee amputations, was incorrectly coded as requiring maximal assistance for putting on/off footwear, despite not having prostheses. These inaccuracies were confirmed through medical record reviews and staff interviews. The Nursing Home Administrator and Lead MDS Coordinator acknowledged the errors upon review. The discrepancies in the MDS assessments indicate a failure in accurately documenting the residents' health status and functional capabilities, which is essential for providing appropriate care and treatment.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide wound care treatments according to professional standards for four residents. Resident #101's significant other was performing wound care without supervision from the facility's wound nurse, who had not been present for several weeks. The care plan required daily evaluation of the wounds, but no documentation of wound assessments was found after the wound nurse left. The facility's staff confirmed that the nurses were expected to provide wound care, but there was a lack of documentation and assessment in the medical records. Resident #21 had an order for daily assessment of a left ankle wound, but the Treatment Administration Record (TAR) showed inconsistent and inaccurate documentation. The resident reported pain and signs of infection, but the TAR did not reflect these observations accurately. The Regional Director of Clinical Operations acknowledged the concern but did not provide additional information. Resident #332 had a right hand wound that was not documented in the medical record, and no wound care order was found. The wound Nurse Practitioner confirmed that there should have been an order for the wound care. Additionally, Resident #74 had multiple instances of undocumented wound care dressing changes, with the Director of Nursing acknowledging the missing documentation and stating that staff would be educated on wound care requirements.
Failure to Maintain Confidentiality of Resident Records
Penalty
Summary
The facility staff failed to ensure the privacy and confidentiality of residents' personal and medical information. During a review of clinical records, it was discovered that a discharge summary and Preadmission Screening and Resident Review (PASRR) form for one resident were incorrectly placed in another resident's clinical record. This error was identified for one resident out of a sample of 48 residents. The Administrator confirmed that the personal information should not have been in the other resident's record during an interview.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by two separate incidents involving two residents. In the first incident, a resident alleged that a Registered Nurse (RN) used profane language and was dismissive when the resident complained about a cold room. The RN admitted to using profanity and being dismissive, but the Nursing Home Administrator (NHA) concluded that the allegation was unsubstantiated due to a perceived lack of intent. The resident did not recall the incident but described the staff as rude. The RN received abuse training following the incident. In the second incident, an anonymous caller informed the Administrator about a video circulating online that showed a staff member verbally abusing a resident. Although no staff members witnessed the abuse, the video was verified, and the staff member involved was terminated. The resident involved did not feel disrespected, and staff education on abuse was conducted. The Director of Nursing (DON) confirmed that another resident had recorded and posted the video, which was later taken down.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility staff failed to ensure the dignity of the residents as evidenced by two specific incidents. First, on 3/18/24, a Geriatric Nursing Assistant (GNA) on the 3rd floor nursing unit was observed without a name tag. When questioned, the GNA acknowledged that the expectation was to wear a name tag at all times and subsequently wrote her name on a piece of tape and placed it on her uniform. Similarly, on 3/20/24, a Registered Nurse (RN) was observed without a name tag after exiting a resident's room. The RN confirmed that the expectation was to wear a name tag at all times. Second, on 3/19/24, another GNA was observed using a personal cell phone while assisting a resident with their lunch. This GNA was also not wearing a name tag and admitted that the facility's policy prohibited cell phone use in resident rooms and required name tags to be worn at all times.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
The facility failed to ensure that personal property was not lost for Resident #28. During an initial tour, Resident #28 reported missing clothes and stated that he/she had informed multiple staff members, including nurses, the Social Service Director, and the Nursing Home Administrator (NHA), about the issue. Despite these reports, no grievance forms were found for Resident #28 regarding the missing items. The surveyor's review of the resident's physical chart also revealed the absence of a personal inventory sheet. Interviews with staff confirmed that the inventory sheet should be in the physical chart, but it was not located. The Social Service Director acknowledged awareness of the missing items and mentioned that the Housekeeping Supervisor was searching for them. However, the NHA was initially unaware of the issue and had not completed a grievance form until prompted by the surveyor. The Housekeeping Supervisor later provided a list of missing items and suggested that the resident's clothes might have been mistakenly donated. The NHA eventually completed a grievance form for the missing items, but this was done only after the surveyor's intervention. The deficiency was further highlighted by the facility's inability to locate Resident #28's personal inventory sheet and the lack of timely grievance documentation. The Housekeeping Supervisor's belief that the resident's clothes were mistakenly donated underscores a lapse in the facility's procedures for handling personal property. The NHA's delayed response and lack of initial awareness of the issue indicate a breakdown in communication and follow-up within the facility. This series of actions and inactions led to the failure to safeguard Resident #28's personal property, resulting in the resident's ongoing distress and inconvenience.
Failure to Timely Report Suspected Abuse Resulting in Serious Bodily Injury
Penalty
Summary
The facility failed to report a reasonable suspicion of abuse resulting in serious bodily injury within the required 2-hour timeframe to the State Agency. This deficiency was identified in the case of a resident who complained of right hip pain on 12/4/23 at 10:49 PM, after returning to their room in a wheelchair. The resident informed the nurse that they had fallen three days prior but had not reported it. An x-ray ordered on 12/5/23 confirmed a right hip intertrochanteric fracture, and the resident was subsequently transferred to a community hospital for urgent surgery on 12/6/23. The initial self-report of the incident was not sent to the State Agency until 12/6/23 at 5:45 PM, which was 2 days and 7 hours after the facility staff became aware of the reasonable suspicion of serious bodily injury. The Administrator confirmed that the facility staff were aware of the incident on 12/4/23 at 10:49 PM, but the delay in reporting violated the requirement to report such incidents within 2 hours. This failure to timely report the incident was evident during the review of the facility's self-report file and interviews with the staff and Administrator.
Failure to Provide Written Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide written notice with the reason for transfer to residents and failed to notify the Ombudsman of residents that transferred. This deficiency was identified in three residents who were hospitalized. Resident #332 was transferred to the hospital in early February 2024, but there was no written notice provided to the resident, and the transfer was not included in the list sent to the Ombudsman. The Nursing Home Administrator acknowledged that only discharges, not transfers, were sent to the Ombudsman for the month of February 2024. Resident #63 was transferred to the hospital due to abdominal pain and vomiting, but there was no documentation that the resident or their representative received written notice of the transfer. Similarly, Resident #109 was transferred to the hospital due to the facility not having appropriate respiratory equipment, but there was no written notice provided to the resident or their representative. Interviews with staff revealed that verbal notifications were given, but written notices were not provided, and no evidence of written notices was presented during the exit conference.
Failure to Develop Baseline Care Plan for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and provide a baseline care plan for two newly admitted residents within 48 hours of their admission. For Resident #125, admitted in late January 2024, the medical record review revealed no baseline care plan note. Although a nursing evaluation was completed on 1/24/24, it did not indicate that care planning was discussed with the resident or that the resident received a summary. The evaluation also lacked documentation of the therapy services planned, the resident's goals, and a summary of medications with dietary instructions. When the surveyor requested the baseline care plan, the Nursing Home Administrator stated that nursing handles baseline care planning in their initial assessment but did not provide additional information by the time of the surveyor's exit.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement appropriate care plans for three residents, leading to deficiencies in their care. Resident #28 was identified as a smoker, with multiple smoking assessments and a smoking contract in place. However, the resident's care plan did not include any information related to smoking until after the surveyors' visit. The surveyors found cigarette butts and an empty cigarette pack in the resident's room, despite the resident denying smoking. Additionally, the resident was observed smoking without an oxygen tank, which was not addressed in the care plan. The Nursing Home Administrator confirmed the absence of a smoking care plan for Resident #28 during the surveyors' visit. Similarly, Resident #125, who had expressed a goal to be discharged to the community, did not have a care plan addressing discharge planning, despite being admitted to the facility in late January 2024. The Nursing Home Administrator acknowledged the lack of a discharge care plan for this resident during the interview with the surveyors. Resident #111's care plan indicated that the resident was independent with bathroom Activities of Daily Living (ADL), yet the staff were using incontinence briefs on the resident. The resident was not on a toileting program to address incontinence, which was inconsistent with the care plan. The Administrator acknowledged the discrepancy and expressed concern over the findings. These deficiencies highlight the facility's failure to develop and implement comprehensive care plans that address the specific needs of the residents, leading to inadequate care and oversight.
Failure to Cut Resident's Toenails
Penalty
Summary
The facility staff failed to ensure that a resident's toenails were cut. This was evident for one resident who had a long toenail on the big toe of the right foot, measuring about one inch above the toe. The resident reported that no one had cut the toenails even after the dressings on the feet were changed. The long toenail was observed again four days later, indicating that the issue had not been addressed. The Regional Clinical Director confirmed that the resident had a podiatry appointment the previous week.
Inadequate Activities Program for Residents
Penalty
Summary
The facility failed to have an activities program designed to meet the interests and needs of residents based on their comprehensive assessment and care plan. This deficiency was evident in two residents reviewed for activities during the survey. Resident #7, who has a medical history including paranoid schizophrenia, major depressive disorder, adjustment insomnia, and mild cognitive impairment, expressed preferences for group activities, keeping up with the news, going outside, participating in religious practices, and doing favorite activities. Despite these preferences, the care plans and documented activities did not align with Resident #7's expressed interests. Observations showed Resident #7 frequently lying in bed, and the activity logs indicated minimal engagement, primarily involving snack delivery and occasional light conversation, failing to meet the resident's stated needs for meaningful activities and social interaction. Similarly, Resident #79 reported that the facility's activities were limited to snacks, music, and conversation, which was corroborated by the activity logs. The logs showed minimal and repetitive activities such as coloring material drop-offs and supply deliveries being counted as activities. The Administrator and Regional Clinical Director acknowledged the lack of adequate activities when shown the documentation. This indicates a systemic issue in the facility's activities program, failing to provide residents with engaging and meaningful activities as per their preferences and care plans.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or less during a re-certification survey. During an observation of medication administration, a Certified Medication Aide (CMA) did not administer Vitamin D to a resident as ordered and incorrectly documented it as given. Additionally, the CMA administered Levothyroxine to another resident after breakfast, contrary to the order specifying it should be given before breakfast. The CMA confirmed these errors during an interview. The surveyor informed the Nursing Home Administrator (NHA) and Director of Nursing (DON) that the medication administration observation resulted in an error rate of 8%.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
The facility failed to maintain a safe and effective system for securing medication and treatment carts on the nursing units. During a random tour of the 1st floor nursing station, a surveyor observed an unlocked medication cart containing medications labeled with residents' names and room numbers. The LPN responsible for the cart confirmed it was his responsibility and acknowledged that the facility's expectation was for the cart to be locked when unattended. Similarly, an unlocked treatment cart was observed on the 1st floor, containing various medical supplies. The LPN responsible for this cart also confirmed it should have been locked when unattended. On a subsequent tour of the 3rd floor nursing unit, another unlocked treatment cart was observed, containing medical supplies such as scissors, ointments, bandages, and dressings. The RN responsible for this cart confirmed it was his responsibility and that it should have been locked. Interviews with the NHA and DON revealed that the facility's expectation was for all medication and treatment carts to be locked when unattended. The NHA mentioned that an in-service had been conducted to address the issue of unlocked carts, but it was unclear how new and agency night shift employees were provided with this education.
Failure to Assist Resident in Obtaining Necessary Dental Care
Penalty
Summary
The facility staff failed to assist Resident #13 in making necessary appointments for dental care or treatment. During an observation and interview, the resident, who had only three teeth left and reported gum pain, revealed that no further dental appointments were made after a dentist recommended extractions during an on-site visit. The resident's medical record showed a history of tobacco use, bilateral above-knee amputations, dementia, and anxiety. Despite the dentist's recommendation for extractions during a visit on 4/3/23, no extractions were performed during subsequent visits on 6/23/23 and 7/5/23, and no further appointments were scheduled. The Administrator acknowledged the failure to assist the resident in obtaining the necessary dental care and treatments.
Failure to Employ Licensed Practical Nurse in Accordance with State Laws
Penalty
Summary
The facility failed to employ a Licensed Practical Nurse (LPN) in accordance with Maryland State laws. During a review of Staff #13's employee file, it was found that the LPN had an active Virginia Practical Nurse License but lacked necessary documentation such as education transcripts, hire application, evaluations, or disciplinary actions. The Nursing Home Administrator (NHA) confirmed that the LPN was hired while residing in Virginia but currently resides in Maryland, as indicated on her I-9 form. The NHA acknowledged awareness of the requirement for nurses to have an active license in the state of their primary residence and stated that Staff #13 has been informed to apply for a Maryland State Board of Nursing license.
Failure to Secure Bed Mattresses
Penalty
Summary
The facility failed to ensure that residents' bed mattresses were properly secured to the bed frames, leading to safety concerns. This deficiency was observed in two residents. Resident #97's mattress was repeatedly found slid over, exposing approximately 4 inches of the bed frame on multiple occasions. Despite the Maintenance Director's acknowledgment of the issue and a promise to inspect the bed, the problem persisted. Resident #97 had a history of falling and required supervision or assistance while moving in bed, as documented in the medical record and Minimum Data Set (MDS) assessment. The last bed inspection for Resident #97's room was completed in May 2023, indicating a lack of regular inspections. Similarly, Resident #85's mattress was observed slid down, exposing the top right corner of the bed frame. Resident #85, who had bilateral amputation and required assistance with transfers and moving in bed, reported using the bed frame to help move around. The Maintenance Director acknowledged the safety concern and promised to inspect the bed. The last bed inspection for Resident #85's room was also dated May 2023. The deficiency highlights the facility's failure to conduct regular and thorough inspections of bed frames and mattresses, leading to potential safety risks for the residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of insects in a resident's room. During a medication administration observation, multiple gnats were observed swarming inside the room. The Director of Nursing (DON) was called to the room and confirmed the infestation, noting that the privacy curtain was covered in gnats. The DON took pictures and reported the issue to the Nursing Home Administrator (NHA). The NHA was initially unaware of the infestation and stated she would investigate. A review of pest logs revealed that the facility had received extermination treatments for gnats.
Failure to Monitor and Document Required In-Service Training for Nurse Aide Staff
Penalty
Summary
The facility failed to monitor staff to ensure required in-service training for nurse aide staff was completed. This deficiency was identified during an employee record review and interviews, specifically for Geriatric Nursing Assistant (GNA) Staff #48. The surveyor noted that the employee file for Staff #48, who was hired on 10/16/2023, lacked documentation of required education. Despite the facility's use of Relias, a computer-based training program, and On Shift, a messaging system, there was no evidence that Staff #48 had completed the necessary in-service training. The staff educator, who had been in the position for two months, confirmed that it was her responsibility to track in-service and education for nursing staff but could not provide the required documentation for Staff #48. Further interviews with the Human Resources Director and the Corporate Human Resource Business Partner revealed that all completed education should be part of the employee's file. However, the only training documentation provided for Staff #48 included modules completed in 2019 and 2020, with only one training completed in 2024. The Nursing Home Administrator confirmed that Staff #48 had been hired in a different position in October 2023 and had previously worked in a different role in 2019. Despite efforts to locate additional education records, none were found, confirming the deficiency in monitoring and documenting required in-service training for nurse aide staff.
Failure to Inform Resident's Representative of Care Plan Changes
Penalty
Summary
The facility failed to honor the rights delegated to a resident's representative by not informing them of changes to the plan of care. Resident #77 was admitted in early August 2023 and was evaluated by two providers in September 2023, who had conflicting assessments regarding the resident's ability to appoint a healthcare representative. Despite the evaluations indicating the resident's incapacity to make informed decisions, the social history assessment completed in October 2023 incorrectly indicated that Resident #77 had decision-making capacity and did not list a healthcare proxy or agent. This discrepancy led to confusion about who should be contacted for decisions regarding the resident's care. Further review of Resident #77's medical records revealed multiple instances where changes in the resident's condition were documented, but the notifications were inconsistently made to either the resident or the ex-spouse, who was listed as an emergency contact. Interviews with staff indicated a lack of clarity and proper documentation regarding the resident's representative. The Nursing Home Administrator acknowledged the oversight and stated that a surrogate form should have been filled out to indicate the decision-maker for the resident, which was not done by the social services staff.
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The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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