Hartley Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Pocomoke City, Maryland.
- Location
- 1006 Market Street, Pocomoke City, Maryland 21851
- CMS Provider Number
- 215134
- Inspections on file
- 17
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Hartley Nursing And Rehab during CMS and state inspections, most recent first.
A resident was discharged to an independent living apartment without home health services or community referrals in place. The responsible staff member was unfamiliar with the discharge process for independent living and did not arrange for home health or meals on wheels until several days after discharge, resulting in a delay in services.
A facility failed to notify a resident with intact cognitive function that their Medicare services were ending, as evidenced by the absence of the resident's signature on the Notice of Medicare Non-Coverage form. The resident confirmed they were not informed about the termination of services and did not receive the notice to sign.
The facility was found deficient in maintaining a clean and homelike environment. Observations revealed damaged walls, cracked tiles, and dirty floors in several residents' rooms. The Administrator acknowledged the issues and mentioned ongoing renovations, but the deficiencies were evident during the survey.
A facility failed to provide written notification to a resident and/or their representative about a hospital transfer, including the reason for the transfer. The deficiency was identified during a medical record review, which showed no documentation of notification. Interviews with the DON and Administrator confirmed the lack of documentation, and the Ombudsman noted inconsistencies in receiving transfer/discharge forms.
A facility failed to notify a resident and/or their representative in writing about the bed hold policy during a transfer to an acute care facility. Medical record review and staff interviews confirmed the absence of written evidence of such notification.
The facility did not create person-centered care plans for two residents. One resident was prescribed Paxil for off-label use to manage sexually inappropriate behavior, but no care plan was in place. Another resident received pain management treatments, including Tylenol, Tramadol, and a steroid injection, yet lacked a care plan for pain management. These deficiencies were confirmed by the DON.
A facility failed to complete a smoking assessment for a resident identified as a smoker in their care plan. Despite the Administrator's claim of a smoke-free environment, the resident was observed smoking outside unattended. The resident's medical record noted their smoking habit, but no assessment was completed. The Administrator confirmed the resident was signed out daily to smoke.
A discrepancy was found in the documentation of a resident's medication. The resident, with anxiety and depressive disorders, was noted by a physician and NP to be on Lexapro for panic attacks, despite the medication being discontinued earlier. This inconsistency was confirmed by the ADON.
The facility was found to improperly store medications and biologicals at incorrect temperatures. During a survey, the North Hall medication storage room's refrigerator and freezer were observed to be above the required temperature limits. The Maintenance Director acknowledged the issue and planned to investigate.
During a survey, a facility was found to have failed in storing food according to professional standards. Items in the kitchen's refrigerators and freezer lacked date labels, including pudding, sandwiches, salsa, peaches, and meat products. The Kitchen Supervisor, new to the facility, acknowledged the issues and noted that temperature logs were incomplete or missing. These concerns were discussed with the Administration team.
Failure to Arrange Home Health and Community Referrals at Discharge
Penalty
Summary
Facility staff failed to ensure that home health services and community referrals were in place at the time of discharge for a resident who was transitioning to an independent living apartment. The resident, who had been admitted for rehabilitation following hospitalization and was later determined not to require skilled nursing services or meet the criteria for nursing facility level of care, was discharged without the necessary referrals for home health and meals on wheels. The referrals were not made until three days after discharge. Interviews revealed that the staff member responsible for the discharge was inexperienced with independent living discharges and was unaware of the resources needed for the resident. The regional social worker became involved after the fact and directed the necessary referrals, which resulted in a delay in the resident receiving home health services. The Director of Nursing confirmed that the facility did not have the required services and referrals in place at the time of discharge.
Failure to Notify Resident of Medicare Service Termination
Penalty
Summary
The facility failed to notify a resident that their Medicare services were ending, along with the right to appeal this decision. This deficiency was identified during a review of the medical records and interviews conducted with the resident and staff. Specifically, the Notice of Medicare Non-Coverage form, which indicated that the resident's Medicare-covered services would end on January 10, 2024, lacked the resident's signature, confirming receipt of the notice. Staff #10 confirmed that the form was not signed by the resident. The resident, who had a BIMS score of 15 out of 15, indicating intact cognitive function, was able to accurately state the current date and confirmed during an interview that they were not notified about the termination of Medicare services and did not receive the notice to sign.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as observed during a survey. In one room, the upper part of the wall above the headboard had ripped drywall with large holes, visible immediately upon entering. The floor had several cracked tiles, was black throughout, and had a broken and peeling baseboard near the sink. Additionally, the shower on the back hall had cracked and yellow-stained glass tiles. These issues were noted during an initial tour and remained unresolved by the time of the survey exit. Further observations revealed that the rooms of three residents were not maintained in a clean state. Two residents' rooms had floors that were dirty with streaks of a black-colored substance, piles of gray dust-like matter, and brown-colored stains under the beds. The Administrator acknowledged the condition of these rooms and mentioned ongoing renovations, but the deficiencies were evident during the survey period.
Failure to Notify Resident of Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and/or their representative regarding a transfer to the hospital, including the reason for the transfer. This deficiency was identified during a review of the medical record of a resident who was hospitalized due to a change in their medical condition. The review revealed that there was no documentation indicating that the resident or their representative was informed in writing about the transfer. Interviews with the Director of Nursing and the Administrator confirmed the absence of such documentation, and it was noted that the facility previously used The Maryland Notice of Involuntary Transfer and Discharge Forms for hospital transfers. Additionally, the Ombudsman reported inconsistencies in receiving transfer/discharge forms for residents.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident and/or the resident's representative in writing of the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during a review of the medical record for a resident who was sent to an acute care facility due to a change in medical condition. The review revealed that there was no written evidence provided to the resident or their representative regarding the bed hold policy. Interviews with two social workers confirmed that they were unable to produce or locate any written notice of the bed hold policy given to the resident or their representative.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for two residents, leading to deficiencies in their care. For Resident #11, the electronic medical record indicated the prescription of Paxil for off-label use to manage sexually inappropriate behavior. However, there was no care plan addressing the use of Paxil or the resident's behavior. The Director of Nursing confirmed the absence of a care plan and noted that the Unit Manager should have completed it. For Resident #21, the medical record showed physician orders for Tylenol and Tramadol to manage right knee pain, and a steroid injection was administered in June 2024 at a pain management clinic. Despite these interventions, there was no care plan developed for pain management. This oversight was identified during the survey, highlighting a gap in the facility's care planning process.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for Resident #56, who was identified as a smoker in their care plan. During the entrance conference, the Administrator stated that the facility was smoke-free and had no smoking residents. However, during observation rounds, Resident #56 was found smoking outside unattended on the facility property. The resident's medical record indicated they were admitted on Hospice and had a care plan noting they were a smoker, but no smoking assessment was completed. The Administrator acknowledged that Resident #56 was a smoker and was signed out daily for a leave of absence to smoke outside.
Discrepancy in Resident Medication Documentation
Penalty
Summary
A deficiency was identified in the documentation of a resident's medical record at the facility. The resident, who was admitted with diagnoses including anxiety disorder and depressive disorder, was seen by a physician and a nurse practitioner on separate occasions. During these visits, both healthcare providers documented that the resident was receiving Lexapro for panic attacks. However, a review of the Medication Administration Record and the Physician Order revealed that Lexapro had been discontinued by the physician prior to these visits. This discrepancy in documentation was confirmed during an interview with the Assistant Director of Nursing.
Improper Medication Storage Temperatures
Penalty
Summary
The facility failed to properly store medications and biologicals under appropriate temperature controls, as observed during a survey. In the North Hall medication storage room, the refrigerator thermometer displayed a temperature of 44 degrees Fahrenheit, and the freezer thermometer showed 30 degrees Fahrenheit. These temperatures exceeded the facility's policy requirements, which mandate that refrigerator storage must be maintained at or below 41 degrees Fahrenheit and freezer storage at or below -4 degrees Fahrenheit. This deficiency was identified during observation rounds conducted with the Maintenance Director, who acknowledged the temperature discrepancies and indicated an intention to investigate further.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store food in accordance with professional standards for food safety, as observed during a recertification survey. During an initial tour of the facility's kitchen, several items inside the Reach In Refrigerator and the main Refrigerator were found without date labels, including nine containers of pudding, one sandwich, a 69-ounce container of chunky salsa, a half-full bucket of peaches, a half-full bucket of bar-b-que sauce, a quarter-full bucket of vanilla pudding, a quarter-full bucket of chocolate pudding, and a half-full bucket of pears. Additionally, inside the Freezer, a large bag containing approximately 15-16 hamburgers and two large bags of meatloaf patties were also found without date labels. The Kitchen Supervisor, who had recently started at the facility, acknowledged these issues during an interview. She mentioned that the hamburgers and meatloaf patties were placed in the freezer by the activities department and expressed her intention to discuss the supervision of these items with the administration. Furthermore, the temperature logs for June 2024 were incomplete, and the July 2024 temperature log was missing entirely. The supervisor stated that temperature logs are supposed to be completed during both morning and evening shifts but was unable to identify who was responsible for the missing July log. These concerns were communicated to the Administration team at the time of the survey exit.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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