Harmony Suites Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Silver Spring, Maryland.
- Location
- 13908 New Hampshire Avenue, Silver Spring, Maryland 20904
- CMS Provider Number
- 215065
- Inspections on file
- 15
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Harmony Suites Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
A resident with dementia, impaired communication, unsteady gait, and documented exit-seeking behavior was not promptly care planned for wandering and was allowed to leave the building by an untrained environmental aide after requesting to go outside. The resident, who self-propelled in a wheelchair and often expressed a desire to go home, waited for an opportunity at a back door and exited when nearby staff stepped away, later reporting a fall during the elopement. Facility staff did not recognize or document the resident as missing for many hours, and the resident was ultimately found by a citizen near a busy street and taken to a police station, then transferred to a hospital, demonstrating a failure to provide adequate supervision and elopement prevention for a cognitively impaired, exit-seeking resident.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with cancer, CKD, and COPD had a documented Port-a-catheter/central IV line in the right chest per hospital records, H&P, multiple MD progress notes, and staff interviews, yet both admission and quarterly MDS assessments coded no IV access. Another resident with diabetes and multiple comorbidities had a hypoglycemic medication (Glipizide ER) placed on hold and then discontinued per MD orders, with the MAR showing no doses given during the look-back period, but the significant change MDS still coded that a hypoglycemic medication was taken. The MDS nurse and Administrator stated that MDS coding should accurately reflect the medical record and care plan, but this did not occur in these cases.
A resident with multiple complex diagnoses, including cancer treated with chemoradiation and an implanted port in the right chest, was admitted with documented central IV access noted in hospital records, nursing notes, and multiple MD progress notes. The facility’s care plan addressed cognitive impairment and risk for abnormal bleeding but did not include any person-centered interventions for the port-a-catheter, such as site care, dressing changes, flushing, line maintenance, or monitoring for complications like infection, occlusion, or dislodgement, nor did it provide staff guidance on managing the central IV line. During interviews, a GNA reported not knowing what type of line the resident had or how it was managed, and an RN stated that IV access care and dressing management were unclear due to the absence of a care plan, while the MDS nurse and Administrator acknowledged that this significant clinical condition and treatment should have been reflected in the care plan.
A resident with a history of chemoradiation and multiple comorbidities was admitted with a central IV port in the chest documented on the admission assessment, but no provider orders were obtained for dressing changes, flushing, or site maintenance for several weeks. During this time, there was no documented assessment or monitoring of the device, and the port remained accessed with a Huber needle in place. Nursing staff reported they did not change the dressing or flush the port due to the absence of orders, the NP confirmed delayed notification about the lack of port-care orders, the DON acknowledged that IV access and dressing changes were not maintained, and the Administrator reported that the oncology provider later stated the port had not been maintained appropriately.
A resident with a Port-a-catheter for chemotherapy and multiple comorbidities was admitted with the port accessed and a dressing in place, but the facility failed to obtain orders or perform required dressing changes, flushing, or site maintenance in accordance with its central venous catheter policy. Despite documentation by providers that the port was present, staff reported that the dressing remained unchanged over time, including during showers, and that no instructions were given regarding IV site care or bathing precautions. Nursing staff and the NP later recognized that the port had remained accessed for weeks without dressing changes, and leadership acknowledged that IV access was not maintained and that the resident was at high risk for infection.
Two residents were observed smoking without required supervision or protective devices, resulting in burn damage to clothing and equipment. Staff interviews and record reviews revealed that care plans and assessments requiring supervision and protective aprons were not followed, and staff misunderstood or did not adhere to facility policy regarding smoking safety.
Surveyors found multiple opened and undated food items in the walk-in freezer, including corn, garlic bread, and Salisbury steak, as well as several containers of dried herbs and seasonings in the food preparation area that were also opened and undated. One seasoning bottle labeled as garlic powder contained an unidentified red powder. The Certified Dietary Manager confirmed these items were not labeled or dated according to facility policy.
Staff failed to follow required procedures for controlled drug security and documentation, including not reporting suspected tampering of narcotic blister cards and not accurately documenting administration of a controlled medication on the narcotic count sheet at the time of administration. These actions resulted in discrepancies and unreported irregularities involving several residents' controlled medications.
The facility did not consistently hold or document required interdisciplinary care plan meetings for several residents, with some not having meetings since admission or for extended periods. Residents and their families reported not being invited to participate, and staff confirmed that meetings were not held as scheduled, often due to staffing shortages and turnover. Record reviews showed missing documentation of care plan meetings following MDS assessments, reflecting a systemic lapse in care planning processes.
Surveyors observed a high medication error rate, with an LPN making multiple errors such as incorrect dosing, improper medication preparation, failure to assess for pain, not offering prescribed treatments, and using medications from other residents. Errors included insufficient water for medication mixing, incorrect administration routes, and not following facility policy for medication administration and water flushes.
Staff failed to maintain complete and accurate medical records, including not reporting tampered narcotic blister cards, not documenting narcotic administration on controlled drug count sheets in real time, and not ensuring required PASRR Level II documentation was present for a resident with a positive mental health screen.
A resident with moderate cognitive impairment alleged that an LPN and two GNAs picked them up and threw them back onto the floor after a fall. Despite the allegation, the facility did not remove the accused staff from the schedule during the investigation, and there was no evidence of abuse in-service training being conducted after the incident. The LPN confirmed continued work with the resident following the event.
A resident did not receive privacy during medication administration when an LPN failed to close the entry door to the room, despite the resident's bed being near the doorway. The LPN acknowledged not following the facility's expectation to provide dignity and privacy during care, which was also confirmed by the DON.
A resident with significant lower extremity impairment and high dependency was repeatedly observed without access to the call bell, which was found on the floor behind the bed during multiple surveyor visits. The resident reported routinely being unable to reach the call bell and having to yell for help, and this was confirmed by both direct observation and staff interview.
A resident was not provided with information about Advance Directives, and there was no documentation in either the electronic or paper medical records to show that this information was offered. The facility's process requires offering and documenting Advance Directive information within a set timeframe, but this was not done consistently, as confirmed by a social worker.
A resident was not provided with the required SNF ABN and NOMNC forms when Medicare Part A coverage ended, and facility staff were unable to locate documentation that these notifications were given. Review of records and interviews with the BOM confirmed the absence of beneficiary notification for continued services after Medicare coverage ended.
Multiple residents experienced unsafe and uncomfortable living conditions, including non-functioning televisions, lack of hot water, a collapsing portable closet, and persistent debris on the floor. Staff were aware of these issues, and in one case, an LPN did not promptly address a resident's request for assistance in removing items from the floor, despite the resident's physical limitations.
Surveyors identified that the facility did not develop or update care plans for two residents: one who refused a palm protector for a hand contracture, and another who was receiving anticoagulant therapy. Staff confirmed the absence of documentation and care plan updates addressing these issues, despite physician orders and ongoing medication use.
A resident with multiple medical conditions was found to have long, thickened, and curled toenails, despite having a physician order for podiatry consult as needed. Staff confirmed the resident's need for podiatry care and described the process for arranging such services, but the resident had not yet received podiatry attention for the overgrown toenails at the time of the survey.
A resident with ongoing vision complaints, including seeing black spots and headaches, repeatedly requested an ophthalmology appointment but did not receive one. Despite staff awareness and available in-house services, the resident remained on a 'Do Not Treat' list due to a missing consent, and the issue was not resolved to ensure timely access to vision care.
A resident with a hand contracture and limited ROM was not provided with the prescribed palm protector device, despite physician orders and documentation indicating daily application. Multiple observations showed the resident without the device, with long fingernails pressing into the palm, and staff were unable to locate the palm protector when requested. Staff interviews and resident statements confirmed inconsistent application and lack of proper documentation of refusals.
A resident receiving nebulizer treatments for wheezing had respiratory therapy equipment, including a face mask and tubing, stored at the bedside without any labeling to indicate when it was put into use or should be replaced. Observations and staff interviews revealed inconsistent practices and understanding regarding the frequency of changing and labeling this equipment, resulting in a failure to maintain respiratory therapy equipment according to professional standards.
A resident was administered PRN Oxycodone for pain levels below the threshold specified in the physician's order. Nursing staff documented and followed a standard pain scale but did not adhere to the prescribed pain parameters, resulting in the medication being given for pain rated at 3 instead of the ordered 5-10 range.
Annual performance reviews for two geriatric nursing assistants were not completed within the required 12-month period, as confirmed by personnel file reviews and facility documentation. This lapse resulted in missed opportunities to assess competencies and identify necessary in-service education for these staff members.
A resident was prescribed Dicyclomine HCl for abdominal cramping, and the consulting pharmacist recommended reviewing its use and considering a stop date, as long-term use is not indicated without a diagnosis of Inflammatory Bowel Disease. The facility did not address this recommendation, and the Medication Regimen Review was not found in the resident's medical record, indicating a lapse in following established procedures for pharmacist recommendations.
Surveyors found that medications were left unsecured in multiple instances, including being left on a nightstand, scattered on the floor, and unattended on top of a medication cart. LPNs admitted to not following facility policy, which requires all medications to be stored in a locked medication cart if not immediately administered.
A resident did not receive routine dental care for three years after being placed on a 'Do Not Treat' list by the contracted dental provider due to missing consent and payer source. Despite physician orders for dental consults and staff awareness of the issue, the DNT status was not addressed, and the resident's dental needs were not met as expected by facility policy.
Surveyors identified lapses in infection control, including a resident's tube feeding pole that was visibly dirty and a lack of a defined cleaning schedule, as well as laundry operations where clean and soiled linens were handled in close proximity, creating a risk of cross-contamination.
Surveyors found four ceiling tiles in the laundry department that were grossly soiled, chipped, and missing. Staff interviews confirmed the tiles had not been replaced and that the soiling was due to rain. The Maintenance Department acknowledged the need for replacement, and the NHA was notified of the issue.
Surveyors observed live and dead roaches in and around the kitchen area during routine inspections, despite staff initially reporting no prior sightings. Multiple pest sightings were confirmed by the Administrator, CDM, and DM, and were subsequently documented in the pest control activity log.
Surveyors observed debris, including used medical gloves and plastic bags, scattered around the outdoor dumpster area instead of being properly contained. The District Manager confirmed that all trash is expected to be disposed of inside the dumpster.
Surveyors found multiple deficiencies in the facility, including missing tiles, broken fixtures, and unsanitary conditions in resident rooms and common areas. Staff interviews revealed a lack of awareness and action regarding these issues, with no maintenance director present for several weeks.
A facility failed to properly identify a resident's health status and representative, leading to unauthorized changes in the resident's code status. The resident's MOLST was altered by a surrogate decision maker without proper documentation or authority, and the attending physician admitted to not fully understanding the legal requirements for such changes.
Two residents experienced physical abuse by staff members. One resident was improperly transferred without a gait belt, causing neck pain, while another was hit by an agency GNA after a wheelchair incident. Both events were confirmed by facility investigations.
A resident's belongings went missing, and the facility failed to implement measures to prevent the loss or theft. A complaint revealed that a nurse was seen taking bags of clothing, and although some items were retrieved, the inventory was outdated and incomplete. Staff interviews showed inconsistencies in labeling and inventory processes.
A resident's clothing was reported missing, and a staff member observed a nurse taking bags to her car. The facility retrieved some items and promised reimbursement but failed to report the incident to the state agency. The complainant reported the matter to the police, and the DON confirmed no report was made to the state agency.
The facility failed to thoroughly investigate reports of abuse and misappropriation involving three residents. In one case, a resident reported being hit by a GNA, but no other residents were interviewed. Another resident's clothing was reported missing, but no formal investigation was conducted. In a third case, a resident's money was allegedly stolen by another resident, but the investigation lacked interviews or statements, leading to an inconclusive result.
A resident's knee bruise was not reported by an LPN to the supervisor or administration, as required by facility policy. The bruise was discovered by an NP during an assessment, leading to a deficiency finding.
A facility failed to provide adequate care to a bed-bound resident with cellulitis and lymphedema, who required extensive assistance for ADLs. The resident reported a lack of care during specific weekends, with no documentation of bowel or bladder movements on several days. Despite improvements, the resident reiterated concerns about the care provided during the reported period.
A resident with Diabetes Mellitus and Dementia did not receive podiatry care during a seven-month stay, despite a physician's order and care plan requiring it. Facility staff indicated that diabetic residents should be seen by a podiatrist, but there was no evidence of such care being provided. The facility's policy required licensed professionals to treat diabetic residents, which was not followed in this case.
A facility failed to provide a timely and accurate discharge summary for a resident who left against medical advice nearly two years prior. The discharge summary was requested during a complaint survey and was inaccurately completed by the attending physician without seeing the resident, as the resident had not returned to the facility. The physician acknowledged the need to understand regulations related to discharge notes.
The facility failed to provide a functioning call system in resident bathrooms, with call bell activation boxes and cords placed out of reach, and indicator lights and audible tones not functioning properly. These issues were confirmed by maintenance staff and the Administrator.
The facility failed to maintain an effective pest control program, with surveyors observing mouse droppings and cockroach activity on multiple floors. Pest issues were documented since early 2024, but the facility did not follow pest control recommendations, leading to ongoing problems. Structural issues in the kitchen and cluttered resident rooms contributed to the infestation.
Failure to Supervise Exit-Seeking Resident Resulting in Unnoticed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implement appropriate interventions to prevent elopement for a resident with known exit-seeking behaviors. On nursing admission, the resident was documented as exhibiting exit-seeking behavior, and later assessments showed dementia with a low BIMS score of 5, impaired communication, unsteady gait, muscle weakness with difficulty walking, and dependence on staff for most ADLs while using a wheelchair for locomotion. Despite this, the resident’s care plan did not address wandering behaviors until more than two months after admission, and the facility’s elopement prevention policy called for interdisciplinary planning, environmental modifications, monitoring, and identification of at-risk residents, which were not effectively implemented for this resident prior to the incident. On the date of the elopement, the resident, who frequently moved up and down the hall in a wheelchair and often expressed a desire to go home, asked an Environmental Service Aide (ESA) to go outside. The ESA, who had been employed less than two weeks and had not been trained in elopement prevention, opened a door and allowed the resident to exit the building. The resident later reported calmly to the NP that they had waited at the back door until an opportunity arose and left when the person nearby stepped away, and also reported losing balance and falling while leaving the building. Staff interviews confirmed that the resident was able to self-propel in a wheelchair but could not walk long distances without it. Following the resident’s departure, facility staff were unaware that the resident had eloped and there was no documentation indicating that the resident was unaccounted for over an approximate eight-hour period between early afternoon and late evening. The resident ultimately ended up at a local police department after being found by a citizen near a busy street and was then sent to a hospital. The DON acknowledged that the last progress note for that day only documented the resident’s lunch and independent eating, with no entries reflecting the resident’s absence during the subsequent hours. Interviews with the Maintenance Director and other staff confirmed that the resident often tried to leave and wanted to go home, yet the supervision and interventions in place did not prevent the elopement event.
Removal Plan
- Implemented a 100% headcount immediately following the elopement incident.
- Assessed Resident #16 immediately upon return from the hospital.
- Placed Resident #16 on 1:1 supervision.
- Ordered labs for Resident #16.
- Completed a full-body skin assessment for Resident #16.
- Placed a wander guard on Resident #16's right wrist.
- Updated the order to reflect wander guard use for Resident #16.
- Updated Resident #16's care plan.
- Updated the elopement binder to include Resident #16.
- Reviewed and revised Resident #16's elopement risk assessment to ensure accuracy and appropriate interventions.
- Completed an elopement drill on each shift.
- Educated staff regarding elopement and obtained staff statements.
- Reviewed all residents for elopement risk.
- Completed and/or updated elopement assessments for current residents.
- For residents identified at risk: obtained wander guard orders, applied wander guards, updated care plans, and initiated behavior monitoring.
- Audited and updated the facility elopement binder to ensure all at-risk residents are accurately identified and tracked.
- Implemented system-wide interventions, including applying wander guards to identified at-risk residents.
- Implemented a Leave of Absence (LOA) pink form process requiring the front desk to be notified before a resident leaves the building.
- Re-educated staff on elopement prevention protocols and the LOA form process.
- Reviewed and reinforced elopement policies and procedures with all staff.
- Conducted ongoing audits of the elopement binder to ensure accuracy.
- Conducted ongoing reviews of LOA documentation for compliance.
- Conducted random resident audits to ensure elopement risk assessments and interventions were in place.
- Reviewed audit results in the QAPI program and addressed identified issues promptly with corrective action.
Inaccurate MDS Coding for IV Access and Hypoglycemic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status and physician-documented care for two residents. For one resident with high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and chronic obstructive pulmonary disease, both the admission and quarterly MDS assessments documented that the resident had no IV access. However, hospital discharge records, the facility history and physical, and multiple provider progress notes consistently documented the presence of a Port-a-catheter/central IV line in the right upper chest used for chemotherapy. A GNA and a staff nurse both recalled that this resident was admitted with an IV line/port in the right chest, confirming that IV access was present despite being coded as absent on the MDS. For another resident admitted with diabetes, COPD, obstructive and reflux uropathy, chronic kidney disease, hypertension, and dementia, a significant change MDS assessment indicated that the resident was taking a hypoglycemic (including insulin) medication during the look-back period. Physician orders showed that the resident’s Glipizide ER 5 mg daily was placed on hold due to lethargy and later discontinued due to poor oral intake and risk of hypoglycemia. The MAR for the same period showed that Glipizide ER was on hold and not administered from early to mid-month, indicating that the medication was not given during the MDS look-back period. Despite this, the MDS was coded as if the hypoglycemic medication had been administered. The MDS nurse and the Administrator both acknowledged that the MDS should accurately reflect the medical record and plan of care, but the assessments for these two residents did not do so.
Failure to Care Plan for Central Venous Access Device
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s central venous access device (port-a-catheter). The resident was admitted with multiple complex diagnoses, including high-grade papillary urothelial carcinoma status post chemoradiation, peripheral vascular disease, chronic kidney disease stage 4, COPD, respiratory failure with hypoxia, and the presence of a cardiac pacemaker, among others. The admission MDS showed the resident was moderately impaired, and the care plan initiated shortly after admission addressed impaired cognitive function and risk for abnormal bleeding due to anticoagulant/antiplatelet use. However, review of the care plan initiated on 11/22/25 revealed no evidence that the presence of a port-a-catheter was addressed. There were no interventions for site care or dressing changes, no interventions for flushing or maintenance of the line, and no monitoring for complications such as infection, occlusion, or dislodgement, and no staff guidance regarding management of the central IV access. Multiple clinical records documented the existence of the implanted port in the right upper chest, including the hospital discharge summary, nursing progress notes, and several provider progress notes by different physicians over multiple days, all confirming the presence of a port-a-catheter or central IV line. During interviews, a GNA recalled that the resident had an IV line in the right chest upon admission but did not know what type of line it was or how it was managed. A staff nurse confirmed that the resident had IV access via a port-a-catheter and stated that care related to the IV access, including dressing management, was unclear due to the absence of a care plan. The MDS nurse acknowledged that the resident had a significant clinical condition and treatment that should have been reflected in the care plan, and the Administrator stated that the care plan should address residents’ clinical needs and guide staff in delivering care.
Failure to Initiate and Maintain Orders for Implanted Port Care
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and obtain treatment orders for an accessed implanted venous port for a resident from admission through several weeks of stay. The resident was admitted with multiple serious diagnoses, including high-grade papillary urothelial carcinoma status post chemoradiation, abdominal aortic aneurysm, atherosclerotic heart disease, peripheral vascular disease, chronic kidney disease stage 4, COPD, respiratory failure with hypoxia, duodenal ulcer, gastrointestinal hemorrhage, dysphagia, obsessive compulsive disorder, major depression, and presence of a cardiac pacemaker. The admission MDS showed the resident was moderately impaired. Nursing admission notes documented a central IV line on the right chest used for chemotherapy, but review of the medical record showed no physician orders for dressing changes, flushing protocols, or site maintenance from admission through mid-December, and no evidence of ongoing assessment or monitoring of the device during that period. On a later date, a nurse documented that the implanted port was present with a Huber needle in place and that there had been no prior orders for care. Physician orders for monthly flushing with saline followed by heparin were not entered until mid-December. In interviews, a staff nurse stated that the dressing on the IV access was not changed and the port was not flushed because no physician orders had been initiated. The NP confirmed being notified weeks after admission that there were no orders for port management, and the DON acknowledged that the facility did not maintain IV access or perform dressing changes and that physician-ordered interventions were not initiated on admission. The Administrator reported that the oncology provider stated the port had not been maintained appropriately and that the lumen remained in place.
Failure to Maintain Infection Control for Accessed Port-a-Catheter
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program for the care and maintenance of an accessed central venous device (Port-a-catheter) for one resident. The resident was admitted with high-grade papillary urothelial carcinoma status post chemoradiation, chronic kidney disease stage 4, and COPD, and had documented impaired cognitive function and moderate cognitive impairment on the MDS. Facility policy for central venous catheters required dressing changes on admission, weekly, and as needed; assessment of the insertion site; use of aseptic technique during dressing changes; routine flushing protocols; and regular needleless connector changes. Record review showed that, despite multiple provider notes documenting the presence of a Port-a-catheter on the right upper chest, there were no physician orders on admission for port dressing changes, flush protocols, or site maintenance. Staff interviews and observations further demonstrated that the accessed port was not properly maintained. A GNA reported that the resident had a dressing with an IV line to the right chest upon admission and that the dressing remained unchanged while the GNA provided showers, with no instructions given regarding IV site care or bathing precautions. A staff nurse recalled seeing the resident with a Port-a-catheter and Huber needle in place with the dressing not changed weeks after admission. The NP stated they were notified weeks after admission that the port remained accessed with no dressing changes performed. The DON confirmed that the facility did not maintain IV access or perform dressing changes and acknowledged the resident was at high risk for infection, and the Administrator reported that the oncology provider indicated the port-a-catheter was not maintained appropriately and that the lumen remained in place.
Failure to Supervise and Provide Protective Devices for Smoking Residents
Penalty
Summary
Surveyors observed that the facility failed to provide adequate supervision and protective devices for residents who smoked, resulting in a deficiency. Specifically, one resident was seen in the dining room with multiple burn holes in their sweatpants and wheelchair cushion, and confirmed these burns were from smoking. This resident was not wearing a protective apron while smoking, despite their care plan and smoking assessment indicating the need for supervision and a smoking apron. Additionally, two residents were observed outside in the designated smoking area unsupervised, with one actively smoking without a protective device and the other holding cigarettes and a lighter without an apron or supervision. Interviews with staff revealed a misunderstanding or lack of adherence to facility policy, as the Activities Director stated that only dependent residents required supervision, contrary to the care plans and assessments for the residents involved. Record reviews confirmed that several residents required supervision and/or protective devices while smoking, but these measures were not consistently implemented. The Director of Nursing confirmed that all smoking residents were expected to be supervised and to use protective devices as required by their care plans and assessments.
Removal Plan
- Educate staff on safety for residents that smoke, supervision, and protective devices.
- Replace burnt clothing, wheelchair equipment, and perform skin assessments for residents who were not provided with protective devices while smoking.
- Review all smoking assessments to determine the safety needs of each smoker and revise as needed.
- Create a list for staff to identify all residents that require supervision and/or a protective device.
- Create a schedule that assigns staff to supervise the smokers during designated smoking times.
- Audit smoking breaks to evaluate whether supervision is being provided as required and whether aprons are being provided as required.
- Address negative findings immediately.
- Report results of audits to the Quality Assurance/Performance Improvement Committee and consider for further action if needed.
Failure to Properly Store and Label Opened Food and Seasonings
Penalty
Summary
During the initial tour of the kitchen, surveyors observed several instances where food items were not stored or prepared in accordance with professional standards and the facility's own food storage policy. Specifically, a clear bag of corn, a clear bag of garlic bread, and a clear bag of Salisbury steak were found opened and undated in the walk-in freezer. Additionally, the corn and garlic bread were stored inside a box labeled for a different food item (broccoli florets). The Certified Dietary Manager (CDM) confirmed that the facility's policy requires opened packages to be securely closed and labeled with the date they were opened, which was not followed in these cases. Further inspection of the food preparation area revealed multiple containers of dried herbs and seasonings that were opened and undated, including bottles of rubbed sage, black pepper, and garlic powder. Notably, the garlic powder bottle contained a red-colored powder, the contents of which the CDM could not identify. The CDM acknowledged that these items were not properly labeled and dated as required by facility policy.
Failure to Follow Standards for Controlled Drug Security and Documentation
Penalty
Summary
Facility staff failed to follow nursing standards of practice regarding the handling and security of controlled medications. During a review of a facility-reported incident, it was found that the backs of several narcotic blister cards for four residents were taped for unknown reasons, with a total of 17 spots on four cards showing clear tape. Nursing staff who conducted the narcotic count noticed the taped blister cards but did not report this irregularity to facility management as required by policy. The facility's policy and the Maryland Nurse Practice Act both require immediate reporting of any suspicion or evidence of tampering or substitution of controlled drug packaging. Additionally, during a shift change narcotic count, a discrepancy was observed between the number of Oxycodone tablets recorded on the controlled drug count sheet and the actual number present in the blister card for one resident. The count sheet indicated 29 tablets, but only 28 were present. The nurse on the outgoing shift stated that he had administered a tablet and documented it on the Medication Administration Record (MAR), but failed to document the administration on the controlled narcotic count sheet at the time of administration. The nurse then documented the administration on the count sheet in the presence of the surveyor and the incoming nurse. Interviews with nursing staff and review of facility policy confirmed that the expectation is for all narcotic administrations to be documented both on the MAR and the controlled narcotic count sheet at the time the medication is removed from the narcotic drawer. The failure to report suspected tampering and to properly document controlled drug administration and counts led to the deficiency cited in the report.
Failure to Hold and Document Routine Care Plan Meetings
Penalty
Summary
The facility failed to conduct routine care plan meetings for several residents, as required by CMS regulations. Multiple residents reported not being invited to or involved in care plan meetings, and record reviews confirmed the absence of documentation for these meetings. Specifically, residents had not received quarterly care plan meetings, and in some cases, had not had a care plan meeting since admission or for extended periods exceeding several months. Interviews with staff, including the Director of Nursing and social work personnel, confirmed that care plan meetings were not being held as scheduled, often due to staffing turnover and absences. For example, one resident had not had a care plan meeting since June of the previous year, and another had not received one since admission in October. Family members of residents also reported not being invited to care plan meetings, despite being designated as Power of Attorney and expressing concerns about the resident's care. Record reviews for additional residents revealed that care plan meetings were not held within the required timeframe following quarterly or annual MDS assessments, with the most recent meetings documented many months prior. Staff interviews further corroborated the deficiency, with admissions that care plan meetings were not up to date and that documentation was lacking. The facility's social work leadership acknowledged that care plan meetings typically follow the MDS schedule but had not occurred in a timely manner due to staffing issues. The absence of care plan meetings and documentation was confirmed for multiple residents, indicating a systemic failure to comply with regulatory requirements for care planning.
High Medication Error Rate Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required, with surveyors observing 13 medication errors out of 28 opportunities, resulting in a 46.42% error rate. Errors were identified during medication administration to three residents, involving both oral and enteral routes. One LPN administered MiraLax without measuring the required amount of water, using only 120 mL (approximately 4 ounces) instead of the instructed 6-8 ounces. The same LPN also failed to assess a resident for pain before administering Tylenol and did not follow the correct procedure for mixing and administering Modular Protein, using less water than directed. Additional errors included administering the wrong dose of ascorbic acid (500 mg instead of the ordered 250 mg) and cholecalciferol (2000 units instead of 1000 units), as well as using medications prescribed for one resident to medicate another. There were also failures to clarify orders, such as administering magnesium oxide via an NG tube to a resident who did not have one, and not clarifying conflicting orders for tube flushes. The LPN also failed to administer a prescribed nebulization treatment, did not attempt to offer it to the resident, and did not follow the correct timing for administering Latanoprost eye drops, which were given in the morning instead of at bedtime. Surveyors observed improper medication administration techniques, such as crushing all medications together instead of one at a time, not following the facility's policy for water flushes between medications, and failing to administer MiraLax as ordered. The LPN also disposed of a significant portion of Peridex mouthwash instead of administering the full dose. These actions and inactions directly contributed to the high medication error rate and demonstrated non-compliance with both physician orders and facility policies.
Incomplete Medical Records and Documentation Failures
Penalty
Summary
Facility staff failed to ensure that medical records were complete and accurate for five residents, as evidenced by multiple deficiencies observed during the recertification survey. During a review of a facility-reported incident, it was found that the backs of several narcotic blister cards for three residents were taped for unknown reasons, with a total of 17 spots on four cards showing clear tape. The facility's policy requires that any tampering or irregularities with narcotic packaging, such as taping, be reported immediately to the Director of Nursing, but nursing staff did not report these taped blister cards as required. Additionally, during a narcotic shift count, a discrepancy was observed between the number of Oxycodone tablets recorded on a controlled drug count sheet and the actual number present in a blister card for another resident. The nurse on the previous shift had administered a tablet and documented it on the Medication Administration Record (MAR) but failed to record it on the controlled narcotic count sheet at the time of administration, only doing so after being prompted during the count. This failure to document narcotic administration in real time is contrary to facility expectations and policy. A further deficiency was identified in the management of PASRR documentation for a resident who had a positive Level I screen for serious mental illness and was referred for a Level II evaluation. The required PASRR Level II documentation was not found in the resident's medical record, and facility staff were unable to produce it despite attempts to locate or obtain it from the agency responsible for the evaluation. This lack of follow-up and incomplete recordkeeping resulted in the absence of critical documentation in the resident's file.
Failure to Remove Alleged Perpetrators During Abuse Investigation
Penalty
Summary
The facility failed to prevent further abuse, neglect, exploitation, and mistreatment from occurring while an investigation into an alleged abuse incident was in progress. A resident with moderate cognitive impairment (BIMS score of 12/15) reported that after falling on the floor, an LPN and two GNAs picked the resident up and threw them back onto the floor. The resident identified the staff involved and repeated the allegation during interviews with both facility staff and local law enforcement. Despite the serious nature of the allegation, the facility did not remove the alleged perpetrators from the work schedule during the investigation, and there was no evidence that abuse in-service training was conducted after the incident. The LPN confirmed that they continued to work with the resident following the reported event. The DON acknowledged that the expectation was for staff accused of abuse to be suspended pending investigation, but this did not occur, as confirmed by staff schedules and interviews.
Failure to Ensure Resident Dignity During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) administered medication to a resident without closing the entry door to the resident's room. The resident's bed was located near the entry door, and the lack of privacy during medication administration was observed by surveyors. The LPN confirmed that the door was not closed during the process, and acknowledged that the facility's expectation is to provide dignity and privacy during care. The Director of Nursing also confirmed that staff are expected to maintain resident dignity, which includes closing the entry door while providing care.
Failure to Ensure Resident Access to Call Bell
Penalty
Summary
Surveyors determined that the facility failed to ensure a resident had access to the facility's communication system, specifically the call bell. During multiple observations, the resident's call bell was found on the floor behind the head of the bed, out of the resident's reach. The resident reported to surveyors that the call bell was always out of reach and that they typically had to yell for help when assistance was needed. This was confirmed during an interview and direct observation with an LPN, who found the call bell on the floor and placed it on the resident's bed. A review of the resident's Minimum Data Set (MDS) assessment revealed that the resident had lower extremity impairment on both sides and required substantial to maximum assistance, indicating a high level of dependency. Despite these needs, subsequent random observations continued to find the call bell on the floor and inaccessible to the resident, demonstrating a repeated failure to accommodate the resident's needs and preferences for communication and assistance.
Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that a resident was offered information regarding Advance Directives. During a review of the electronic medical record and paper chart for one resident, there was no evidence of an Advance Directive on file or documentation that information about Advance Directives had been provided to the resident. This review was conducted on two separate occasions, and both times, the required documentation was absent. An interview with a social worker revealed that the facility's process requires staff to attempt to obtain an Advance Directive within seven days of admission and, if the resident does not have one, to offer information and document this in the chart. The social worker confirmed that this process had not been completed consistently and verified that there was no documentation for the resident in question indicating that Advance Directive information had been offered.
Failure to Provide Required Medicare Beneficiary Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices to a resident who remained in the facility after Medicare Part A benefits ended, despite the resident having benefit days remaining. Record review showed that the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and the Notice of Medicare Non-Coverage (NOMNC) were not provided or documented for this resident. The SNF ABN is intended to notify residents that their services may no longer be covered by Medicare, while the NOMNC informs them of their right to appeal the decision and request an expedited review. Interviews with the Business Office Manager (BOM) and review of facility forms confirmed that the required notifications were not completed or could not be located for the resident in question. The BOM acknowledged the absence of documentation and was unable to find evidence that the resident had been informed about the end of Medicare A coverage. The deficiency was identified through review of both the resident's medical record and the facility's internal notification review forms.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple deficiencies observed in resident rooms. One resident was found with two non-functioning televisions, one of which was left on top of a portable closet, and the hot water to the sink was not working due to a previously broken pipe. The resident also had a protruding electrical socket behind the bed and dislodged ceiling tiles in the bathroom, all of which contributed to an unsafe and uncomfortable living space. The resident reported that staff were aware of the broken television and hot water issue, but these problems persisted. Another resident's portable closet was found collapsing, with the top shelf detached and the side wall pushed outward, creating a risk of further damage or injury. Additionally, a third resident, who was dependent and required substantial assistance due to lower extremity impairment, had more than 20 pieces of candy and a container on the floor next to the bed for several days. The resident was unable to pick up the items due to their medical condition and had previously notified an LPN, who acknowledged awareness but did not remove the items promptly. These findings demonstrate a lack of timely response to environmental hazards and maintenance needs, directly impacting residents' safety and comfort.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, specifically regarding a resident's refusal to use a palm protector and another resident's use of an anticoagulant. For the first resident, observations revealed a left hand contracture with long fingernails pressing into the palm, and no palm protector in use despite an active physician order. Nursing staff confirmed the resident had a history of refusing both nail care and the palm protector, but there was no documentation or care plan update addressing these refusals. The care plan only included the use of the palm protector and monitoring for skin breakdown, without any mention of the resident's non-compliance or alternative interventions. For the second resident, records showed ongoing use of an anticoagulant medication, but there was no care plan developed to address this therapy. Interviews with nursing staff and the DON confirmed that care plans should be updated with changes in condition or medication, but acknowledged that the care plan for anticoagulant use was missing. The deficiency was identified through observation, record review, and staff interviews, with facility leadership being made aware of the lack of appropriate care planning.
Failure to Provide Timely Podiatry Services for Overgrown Toenails
Penalty
Summary
A deficiency was identified when a resident with paraplegia, seizures, adult failure to thrive, and major depressive disorder was observed to have long, thickened, and curled toenails on both feet while lying in bed. The resident's clinical record included a physician order for a podiatry consult as needed, but there was no evidence that podiatry services had been provided to address the overgrown toenails. Staff confirmed the resident's condition and described the process for arranging podiatry care, which involves faxing orders to the service provider and scheduling appointments as needed. However, at the time of the survey, the resident had not yet received podiatry care for the observed condition.
Failure to Provide Timely Vision Services Due to Unresolved Consent Issue
Penalty
Summary
A deficiency was identified when a resident reported ongoing vision concerns, including seeing black spots and experiencing headaches, to nursing staff and the primary attending physician. Despite these complaints, documentation showed that the resident had not received an ophthalmology appointment after reporting these symptoms. The resident had previously requested to see an ophthalmologist and was aware that such services were available in the facility, but did not receive the needed evaluation. Record review revealed that the resident had been placed on a 'Do Not Treat' (DNT) list for optometry services due to a requirement for new consent, and this status persisted across multiple months. Staff interviews confirmed that the resident's need for vision services was known, and that the DNT status was not addressed to facilitate the necessary appointment. The Director of Nursing acknowledged that the expectation was for residents to receive eye exams when requested, but this did not occur for the resident in question.
Failure to Provide Prescribed Palm Protector for Resident with Hand Contracture
Penalty
Summary
A deficiency was identified when a resident with a left hand contracture and limited range of motion was not provided with the prescribed palm protector device, as ordered by the physician. Observations on multiple occasions revealed that the resident's left hand was clenched, with long fingernails pressing into the palm, and no palm protector was in use. The resident's medical record included an active order for a left palm protector to be worn daily after ADL care and removed at bedtime. However, during the survey, the resident was repeatedly observed without the device, and staff were unable to locate it when asked. Nursing staff interviews indicated that the palm protector was documented as applied daily on the Treatment Administration Record, except for one date, but direct observation and the resident's own statement contradicted this documentation. Staff also reported that the resident had a history of refusing nail care and the palm protector, but there was no evidence of consistent application or appropriate documentation of refusals. The deficiency was brought to the attention of facility leadership after these findings.
Failure to Label and Maintain Respiratory Therapy Equipment
Penalty
Summary
The facility failed to maintain respiratory therapy equipment according to professional standards of practice for a resident receiving nebulizer treatments with Ipratropium-Albuterol for wheezing. During multiple observations, the resident's nebulizer face mask and tubing were found stored in a clear plastic zip lock bag on the bedside table without any labeling to indicate when the equipment was put into use or when it should be replaced. Clinical record review confirmed ongoing physician orders for nebulizer treatments every six hours. Staff interviews revealed inconsistent understanding of the facility's policy, with one LPN stating the equipment should be changed and labeled daily, while the Director of Nursing stated the expectation was every seven days. The lack of labeling and clear adherence to equipment change protocols led to the deficiency.
Failure to Follow Pain Medication Parameters for PRN Administration
Penalty
Summary
The facility failed to ensure that pain medication was administered according to professional standards of practice for a resident requiring pain management. Specifically, a physician order directed that Oxycodone HCl 15 mg (2 tablets) be given orally every 6 hours as needed for pain levels rated 5-10, with instructions to hold the medication if the resident was sedated. However, review of the Medication Administration Record (MAR) showed that staff administered the medication on multiple occasions when the resident reported a pain level of 3, which was below the threshold specified in the physician's order. Interviews with nursing staff revealed that nurses followed a standard 0-10 pain scale, asking residents to rate their pain and documenting this prior to administering PRN pain medications. Despite this, the medication was given outside the prescribed parameters. The Director of Nursing, Executive Director, and Nursing Home Administrator were subsequently made aware of the issue.
Failure to Complete Annual Performance Reviews for Geriatric Nursing Assistants
Penalty
Summary
The facility failed to conduct annual performance reviews for two geriatric nursing assistants within the required 12-month period. Personnel file reviews showed that one staff member's review was due in May 2024 and another's in August 2024, but neither review was completed for the calendar year 2024. This deficiency was confirmed through documentation provided by the Executive Director and acknowledged by the Director of Nursing. The lack of timely performance reviews prevented the identification of in-service education needs and assessment of competencies for these staff members.
Failure to Address Pharmacist's Medication Review Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to a recommendation made by the consulting pharmacist regarding a resident's medication regimen. Specifically, a resident was receiving Dicyclomine HCl 20 mg every 8 hours for abdominal cramping, and the consulting pharmacist noted in the November 2024 Medication Regimen Review (MRR) that long-term use of this medication is not indicated unless the patient has a diagnosis of Inflammatory Bowel Disease. The pharmacist recommended reviewing the use of Dicyclomine and adding a potential stop date if possible. Upon review, the surveyor was unable to locate the MRR in the resident's electronic or paper medical record. Interviews with staff revealed that pharmacy recommendations were typically faxed to the DON, who then forwarded them to the attending physician for review and action, with nurses filing the MRR in the paper chart. However, it was confirmed that the November 2024 pharmacy recommendation for this resident was not addressed, resulting in a failure to follow up on the pharmacist's recommendation as required by facility policy.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors identified that medications and biologicals were not consistently stored in accordance with professional standards. In one instance, a resident reported that a nurse left medications on the nightstand for the resident to take after breakfast, rather than returning them to the locked medication cart when the resident initially declined to take them. Observations confirmed that a medication cup with multiple medications was left unsecured in the resident's room. The LPN acknowledged that facility protocol required medications to be returned to the locked cart if not immediately administered. In another case, surveyors observed multiple loose tablets scattered on and under a resident's bed, as well as a medication cup with several medications left on a tray table. The LPN admitted to leaving the medications at the bedside after the resident declined them, instead of securing them as required. Additionally, a separate observation found an LPN leaving a bottle of Anbesol and a tablet of digoxin unattended on top of the medication cart while entering a resident's room. The LPN later confirmed that medications should not be left unsecured. These actions resulted in medications being left unattended and not properly secured as per facility policy.
Failure to Provide Routine Dental Services Due to Unresolved Do Not Treat Status
Penalty
Summary
A deficiency was identified when a resident reported not having received a dental cleaning in three years, despite having requested a dental appointment. The resident's medical record showed a physician's order for dental and other specialty consults as needed, but there was no evidence that a dental appointment had been scheduled or provided. Interviews with staff revealed that the resident was listed as 'Do Not Treat' (DNT) for dental services by the contracted provider, HealthDrive, due to a need for new consent and a payer source. This DNT status had been in place for several years, as confirmed by multiple HealthDrive lists reviewed by the surveyor. Further interviews with nursing staff and the DON confirmed that the facility was aware of the DNT status and the reasons for it, which included insurance issues and the need for updated consent. The DON stated that the facility's expectation was to provide routine dental services every six months and to cover costs if insurance was unavailable. However, the DNT status for this resident was not resolved, and the resident did not receive routine dental care as required, resulting in a failure to provide necessary dental services.
Infection Control Deficiencies in Resident Care and Laundry Operations
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in both the resident care and laundry departments. In one instance, a resident who required tube feeding was observed with a visibly dirty feeding pole at the bedside, with dark brown spots along its base and shaft. Staff acknowledged the unclean condition and indicated that both housekeeping and nursing staff were responsible for cleaning the pole, but there was no awareness of a specific cleaning schedule. The surveyor requested documentation of cleaning logs, but these were not provided by the time of survey exit. Additionally, the laundry department was found to have practices that allowed for potential cross-contamination between clean and soiled linens. Clean linen was folded and stored on tables and in cubicles located directly next to the stairway door, which served as both the entry point for soiled linen and the exit for clean linen. Staff interviews confirmed that this process resulted in clean and dirty linens being handled in close proximity, with no separation between the two, and that this was the established practice within the facility.
Unsanitary and Damaged Ceiling Tiles in Laundry Department
Penalty
Summary
During the annual recertification survey, surveyors observed that the laundry department in the basement had four ceiling tiles that were grossly soiled with large brown stains, chipped, and missing. The laundry aide present during the tour confirmed the condition of the tiles. When interviewed, the Environmental Services (EVS) Director stated that the Maintenance Department was responsible for replacing the ceiling tiles and explained that the soiling was due to rain from outside. The Maintenance Assistant acknowledged the need for replacement of the tiles. The Maintenance Department is located adjacent to the laundry department. The Nursing Home Administrator was notified of the condition of the ceiling tiles in the laundry department.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple direct observations of roaches in and around the kitchen area during the annual survey. On several occasions, surveyors, along with the Administrator, Certified Dietary Manager (CDM), and District Manager (DM), observed live and dead roaches in the hallway outside the kitchen, under the steam table during meal preparation, and in the dietary office. Both the CDM and DM initially stated they had not seen roaches in the kitchen area prior to these observations. The pest control activity log confirmed that the sightings were documented and reported by staff on the same day they occurred.
Improper Disposal of Outdoor Garbage and Medical Waste
Penalty
Summary
During an annual survey, an observation was made of the facility's outdoor refuse area, where debris was found scattered around the dumpster. The debris included several pairs of used medical gloves and clear plastic bags on the ground, rather than being properly contained within the dumpster. In an interview, the District Manager confirmed that the facility's expectation is for all trash to be disposed of inside the dumpster and acknowledged that the scattered debris and trash would be disposed of immediately.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment, as observed by surveyors during rounds. On the 2nd floor, a room was found with missing ceramic wall tiles, a hole in the wallboard, cracked floor tiles, and a shared bathroom with a broken shower head bracket and crumbling walls. The ceiling panels were not securely fitted, and a toilet plunger was left uncovered on the floor. Similar issues were noted in the hallway, with shoe molding pulled away from the wall, exposing gaps and scrapes on the walls. On the 1st floor, the surveyor observed splintered handrails, missing shoe molding, and exposed wall plaster. Several outlets had loose plates, and there were holes and scrapes in the walls. In one room, the bedside table was dirty, and there was a foul smell. The windowsill was cluttered and dirty, with bugs and cobwebs present. Mouse droppings were observed on the floor, and the bathroom tiles were disintegrating. The kitchen also had issues, including a door that did not fully close, peeling paint, and cobwebs in the dry storage room. Interviews with staff revealed a lack of awareness and action regarding these deficiencies. A maintenance technician indicated that there had been no maintenance director for several weeks, and the Culinary Director was unaware of a large hole in the kitchen wall. During a walkthrough with the Administrator and staff, they were shown the concerns, but issues such as non-functioning water in a sink persisted. These observations highlight the facility's failure to provide a safe and clean environment for its residents.
Improper Change of Resident's Code Status Without Proper Authority
Penalty
Summary
The facility failed to accurately and appropriately identify a resident's health status and representative to change the resident's code status. This deficiency was identified during a complaint survey involving a resident with chronic obstructive pulmonary disease and rheumatoid arthritis. The resident was initially admitted with a Maryland Orders for Life Sustaining Treatment (MOLST) form indicating full code status, as per the health care agent named in their advance directive. However, the MOLST was later changed to 'do not intubate' and subsequently to 'do not resuscitate' by a surrogate decision maker, identified as the resident's child, without proper documentation or authority. The medical record lacked any advanced directive documentation or certifications of medical ineffectiveness that would authorize a surrogate decision maker to alter the MOLST. The attending physician admitted to changing the MOLST without full awareness of the relevant policies, procedures, and legal requirements regarding who has the authority to make such changes. This oversight was discussed with the facility's nursing home administrator and regional nurse, highlighting the concern that the surrogate decision maker did not have the proper authority to change the resident's MOLST.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by staff members. In the first incident, a resident complained of painful activities of daily living (ADL) care due to an improper transfer by a Geriatric Nursing Assistant (GNA). The GNA did not use a gait belt, an assistive device necessary for safe transfers, which resulted in the resident experiencing neck pain. The facility's investigation confirmed that the GNA did not follow proper procedures, opting to complete the task quickly instead. In the second incident, a resident in a motorized wheelchair accidentally backed over an agency GNA's feet, pinning the GNA to the wall. In response, the agency GNA physically hit the resident. This event was witnessed by an RN Supervisor and reported by the resident to an LPN. The facility's investigation confirmed the physical abuse by the agency GNA.
Failure to Prevent Loss or Theft of Resident Belongings
Penalty
Summary
The facility staff failed to implement measures and reasonable care to prevent the loss or theft of a resident's belongings, specifically for one resident. A complaint was made regarding the disappearance of three bags of clothing belonging to the resident. The complainant reported seeing a nurse taking bags of clothing to her car, and although two bags were retrieved by the administrative staff, the third bag was not returned, and reimbursement had not been received. The facility's policy required an inventory of personal items to be completed and updated, but the inventory for this resident had not been updated since admission, and there was no evidence of the missing items being recorded. Interviews with staff revealed inconsistencies in the process of labeling and inventorying residents' belongings. The laundry staff indicated that they label clothing based on the name on the laundry bag, while the laundry supervisor stated that nursing staff were responsible for inventorying belongings. The facility's policy required an inventory sheet to be completed at admission and updated with any changes, but the inventory for the resident in question was outdated and incomplete. The facility failed to ensure that staff consistently followed procedures to prevent the loss or theft of resident belongings.
Failure to Report Misappropriation of Resident Belongings
Penalty
Summary
The facility staff failed to report an allegation of misappropriation of a resident's belongings to the State Agency. A complaint was reviewed regarding a resident whose clothing was reported missing. The complainant discovered that three bags of the resident's clothing were missing and reported it to a staff member at the front desk, who mentioned observing a nurse taking bags of clothing to her car. The administrative staff retrieved two of the three bags and promised reimbursement for the third. However, the complainant never received further communication from the facility, and the incident was reported to the police by the complainant. The Director of Nursing confirmed the lack of evidence that the facility reported the incident to the state agency.
Failure to Investigate Abuse and Misappropriation Reports
Penalty
Summary
The facility staff failed to conduct thorough investigations following reports of abuse and misappropriation of resident property, affecting three residents. In the first case, a resident reported being hit by an agency GNA, but the facility did not interview other residents on the unit to determine if they also experienced abuse or felt unsafe. The Director of Nursing confirmed this oversight during an interview. In the second case, a complaint was made regarding missing clothing belonging to a resident. Although some of the clothing was retrieved, the facility did not conduct a formal investigation into the incident, and the complainant did not receive further communication from the administration. In the third case, a resident's roommate reported witnessing another resident stealing money, but the facility's investigation lacked interviews or written statements from involved parties, leading to an inconclusive result. The Regional Nurse confirmed the absence of additional investigation documentation.
Failure to Report Resident Injury
Penalty
Summary
The facility nursing staff failed to adhere to professional standards of practice by not reporting a resident's injury to a provider. Specifically, a Licensed Practical Nurse (LPN) did not report the formation of a bruise on a resident's left knee to their supervisor or administration. This incident was discovered when a Nurse Practitioner (NP) assessed the resident and found the bruise. The facility conducted an investigation and confirmed that the LPN was aware of the bruise earlier in the day but did not report it, leading to a deficiency finding during a complaint survey.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate care to a resident who was dependent on staff for activities of daily living (ADL). The resident, diagnosed with cellulitis and lymphedema in the bilateral lower extremities, was bed-bound and required extensive assistance from two people for toileting. The complaint highlighted a lack of care during specific weekends in March 2022, where there was no documentation of bowel or bladder movements for the resident on several days. Despite improvements in care, the resident reiterated concerns about the lack of care and treatment during the reported period. The quarterly minimum data set completed in January 2022 confirmed the resident's frequent incontinence and need for extensive assistance, yet the necessary ADL care was not documented or provided during the specified times.
Failure to Provide Podiatry Care for Diabetic Resident
Penalty
Summary
The facility staff failed to provide appropriate foot care for a resident, identified as Resident #34, who was admitted with diagnoses including Diabetes Mellitus and Dementia. During the resident's seven-month stay, there was a physician's order for a podiatry consult, which was part of the care plan addressing the resident's diabetes. The care plan included interventions such as podiatry consults and monitoring of skin integrity and foot care. However, a review of the medical records revealed no documentation that the resident was seen by a podiatrist, as required by the physician's order and the care plan. Interviews with facility staff, including the DON and an LPN, indicated that diabetic residents were supposed to receive foot care from a podiatrist, and new admissions were automatically placed on a list for podiatry visits. Despite this process, the Regional Nurse confirmed the absence of evidence that the resident received the necessary podiatry care. The facility's policy stated that diabetic residents should be treated by licensed professionals, yet this was not adhered to in the case of Resident #34, leading to the deficiency noted in the survey.
Failure to Provide Timely and Accurate Discharge Summary
Penalty
Summary
The facility failed to have a discharge summary on the medical record for a resident who was reviewed during a complaint survey. The deficiency was identified when the medical record for a resident was reviewed in response to a complaint related to timely discharge. It was found that there was no physician discharge summary on the chart, despite a request for it. A discharge summary was later provided to the survey team, dated the same day it was requested, and inaccurately stated that the resident was seen 'TODAY' in their room. However, records indicated that the resident had left the facility against medical advice nearly two years prior and had not returned. The attending physician admitted to completing the discharge summary without seeing the resident and acknowledged a need to become familiar with regulations regarding the timeliness of discharge notes.
Deficient Call System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure a functioning call system was available in each resident's bathroom and bathing area, as observed during a tour. In one instance, the call bell activation box in a shared bathroom was mounted approximately 6 feet above the floor, with a short red cord ending about 5 feet above the floor, making it inaccessible to residents sitting or lying on the shower floor or seated on a shower chair. In another bathroom, the call bell activation switches were located on the walls to the left and right of the toilet. The switch on the left was in the off position with no pull cord, preventing activation by a resident lying on the floor. The switch on the right was in the activated position, but the indicator light in the hallway was not lit, and there was no audible sound at the nurse's station. Further observations confirmed that the call bell switches remained in the same positions, and issues persisted with the indicator lights and audible tones. During a follow-up observation, the left switch illuminated a red indicator light and produced an audible tone in the hallway when flipped down, but the hallway ceiling light failed to illuminate. The right switch failed to activate any indicator light or tone when toggled. These deficiencies were confirmed by the Maintenance Director, a maintenance assistant, and the Administrator during walking rounds.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of mouse droppings and cockroach activity observed by the survey team on the 1st and 2nd floors. The pest activity was noted in resident rooms over several days, and the facility's pest control records revealed a history of ongoing pest issues that were not adequately addressed. The Maintenance Director confirmed that a pest control company visited the facility every three months, but the facility did not follow the company's recommendations, leading to continuous pest activity. During a tour of the facility, live roaches were observed in a resident's room, where the resident was eating snacks with crumbs scattered around. The room was cluttered, with open dresser drawers and items in disarray, potentially contributing to the pest problem. The facility's pest control documentation system, TELS, indicated that the roach problem had been documented since February 2024, with repeated concerns in various areas, including the kitchen and nursing stations. In the kitchen, structural issues such as unsecured ceiling tiles and a hole in the wall were identified, which could attract pests. The Culinary Director was unaware of these issues and had not reported them in the maintenance system. Pest control logs showed previous sightings of roaches in the kitchen, but the Culinary Director did not provide recent updates. The facility's failure to address these environmental concerns and follow pest control recommendations resulted in ongoing pest issues, potentially affecting all residents.
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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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