Lions Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cumberland, Maryland.
- Location
- 901 Seton Drive, Cumberland, Maryland 21502
- CMS Provider Number
- 215073
- Inspections on file
- 22
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Lions Rehab Center during CMS and state inspections, most recent first.
A resident with an ADL self-care deficit and a care plan requiring assistance to the toilet/commode with maximum assistance of one staff was placed in a room where the bathroom was out of order due to renovation. During an incident involving alleged abuse/neglect, a GNA reported attempting to assist the resident to the bathroom, discovering it was under construction, and instead providing a bedpan. The DON later confirmed that the bathroom was nonfunctional at admission because the floor was setting and acknowledged that a commode should have been available, indicating the resident’s toileting needs and preferences for toilet/commode use were not reasonably accommodated.
A resident who had been determined unable to make medical treatment decisions and had a designated healthcare power of attorney developed a new genital wound that was evaluated by a wound provider and documented by an RN as a change in condition. The RN recorded that the resident, described as alert and oriented, refused to allow family notification, and no notification of the responsible party occurred. In an interview, the DON acknowledged that the responsible party should have been notified of the new skin condition and required treatment.
A resident urgently requested assistance to use the toilet, stating they had been asking for help for a long time and feared wetting themselves, but the assigned GNA told the resident to go ahead and wet the bed because they were serving breakfast trays and would clean the resident later, then left without providing the requested care. When another GNA later returned to collect breakfast trays, the resident again reported needing to use the bathroom and believed they had started to wet themselves. Other residents reported that the same GNA frequently delayed or failed to return to provide promised baths and incontinence care, stated they did not have time to change residents, expressed hating their job when asked for help, and made residents feel afraid to request assistance, including during painful bathing. The coworker GNA confirmed their account, and the facility’s investigation verified the allegation of verbal abuse and neglect.
Surveyors found that the facility failed to timely revise care plans after changes in condition for two residents. One resident had new physician orders for PRN and then continuous O2 via nasal cannula, was observed on O2, yet had no care plan addressing oxygen use; the DON acknowledged the care plan should have been updated. Another resident, admitted earlier in the month, sustained a fall from bed, with an RN note indicating fall protocol was initiated; although a fall-risk care plan existed and was revised to add monitoring for medication side effects, it did not capture the actual fall or fully reflect existing risk factors. Only after a second fall was a more detailed fall-risk care plan created, documenting history of falls and multiple contributing conditions that were already present after the first fall, which the DON agreed were not captured in the earlier revision.
A resident’s coccyx wound care was not consistently ordered or documented after a change in treatment orders. An initial order directed application of skin guard ointment to both the genital area and coccyx each day and evening, but when the order was changed, it specified only the genital area and omitted the coccyx. No coccyx wound treatment was ordered or documented for several days until a new order was written to cleanse the wound, apply medi-honey, and cover with a border foam dressing. During an interview, the DON acknowledged the concern and was unable to provide additional documentation of coccyx wound care for the gap period.
A resident with increased behaviors had lorazepam changed from PRN to scheduled BID and was also started on Depakote BID for behaviors and agitation. Over several days, lorazepam doses were left blank on the MAR, indicating they were not given, while Depakote was documented as administered after an initial "not available" entry. Progress notes alternately stated that lorazepam was not given due to pharmacy and unsigned-provider-order issues and, on other entries, that it was given as ordered, yet these administrations were not reflected on the MAR. In an interview, the DON stated that the pharmacy would not release medication without a signed order and acknowledged that the medication should have been administered as ordered and properly documented.
A resident on comfort care for pain management did not receive the correct dose of morphine as ordered, with nursing staff administering only 0.25 ml instead of the prescribed 5 ml per dose over multiple administrations. Additionally, an agency LPN failed to document five administrations of the medication, as confirmed by the DON after review of records.
A resident on comfort care received incorrect doses of morphine for pain management after nursing staff administered a discontinued morphine solution multiple times, rather than the newly ordered concentration. The DON confirmed that the wrong medication was used and that the error was not prevented.
A resident's physician was not notified when doses of metoprolol were withheld due to low blood pressure or heart rate, as documented in the MAR. Review by the DON and Regional Nurse confirmed the absence of physician notification for these missed doses.
The facility did not complete a thorough investigation into an allegation of verbal abuse involving a resident. Interview statements from residents lacked interviewer names and dates, staff interviews were incomplete, and there was no list of staff present during the incident or evidence of abuse education provided to staff. The DON confirmed the investigation's deficiencies.
A resident who suffered an unwitnessed fall and fractured their left wrist had conflicting medical records filed, with duplicate documents indicating both the right and left wrist as affected. The DON and orthopedic PA could not confirm who altered the documentation, and the facility accepted the amended record without proper verification, resulting in a deficiency for failing to maintain accurate medical records.
Surveyors found that several residents did not receive prescribed medications and treatments, including pain management, diabetes care, thyroid medication, and port monitoring. The DON confirmed that these omissions occurred and that there was no documentation to show the care was provided.
A resident with a Foley catheter was found with their urine collection bag resting on the floor, contrary to the care plan instructions to keep the bag above the floor and below bladder level. The assigned GNA confirmed the situation during surveyor observation and acknowledged the bag's improper placement.
Staff failed to document complete pain assessments—including pain location, description, and use of non-pharmacological interventions—when administering PRN pain medications to two residents. Pain intensity was sometimes recorded, but other required assessment elements and interventions were missing, as confirmed by the DON.
A resident continued to receive both a 40 mg and a 20 mg daily dose of an antiulcer medication after a provider ordered a reduction to 20 mg daily, resulting in a medication error confirmed by the DON.
Staff failed to implement Enhanced Barrier Precautions (EBP) for two residents with pressure ulcers, as required by infection prevention protocols. During wound care, staff did not wear protective gowns, and there was no documentation, care plan indication, or physician order for EBP. The DON confirmed EBP should have been used for these residents.
The facility failed to monitor and document temperatures for the dishwasher and certain food items, compromising sanitation and food safety. During a GI outbreak, the dish machine log was not updated for several days, and food temperature logs lacked documentation for pureed and mechanical soft diets on three occasions.
The facility failed to ensure accurate MDS assessments for several residents, leading to discrepancies in documentation. One resident was incorrectly recorded as having natural teeth, while another's insulin use was inaccurately documented. Additionally, a resident's pressure ulcer documentation was inconsistent with available records. The DON confirmed these inaccuracies during interviews.
The facility failed to update a resident's care plan to reflect a decline in functional abilities and did not include another resident in their care plan meeting despite being off isolation. The RN responsible for care plan meetings was not informed of changes in the resident's condition, and the resident capable of making decisions was not followed up with after the meeting.
The facility failed to provide adequate assistance to residents during meals and incontinence care, as evidenced by missing documentation and interviews with the DON. Several residents requiring extensive assistance with eating had missing documentation for meal assistance on multiple days. Additionally, residents needing incontinence care were found in soiled briefs or reported being left soiled, with documentation confirming a lack of care on specific days. These deficiencies were confirmed through interviews and documentation reviews.
The facility failed to document and manage pain effectively for residents, including a resident with chronic pain and another with a crushing injury. PRN pain medications were administered without proper documentation of pain assessments or non-pharmacological interventions (NPIs) as required by the facility's policy. The DON acknowledged the lack of documentation and confirmed that NPIs should precede medication.
The facility failed to ensure the dignity of two residents with urinary catheters by not using privacy bags for their urine collection bags. Observations showed the bags were visible from the hallway, and staff acknowledged the issue.
A facility failed to provide a resident with quarterly statements of their personal funds account, despite the resident being capable of making their own decisions. The BOM admitted to only providing copies upon request, leading to the deficiency as the resident had not received a written statement for a year.
A facility failed to inform a resident of their right to formulate an advance directive. The resident, capable of making decisions, had no documentation of being informed about this right. The nurse manager, acting as the social services designee, only asked if residents had existing directives and did not discuss creating one if they did not. This occurred after the facility lost their social worker, and the nurse manager assumed additional duties.
A facility failed to notify a physician when a resident's Metoprolol was held multiple times due to low systolic blood pressure (SBP) and heart rate, as per the medication order for cardiomyopathy. Despite the order to hold the medication if the pulse was below 60 or SBP was below 100, the physician was not informed of these instances, as confirmed by the primary care physician. The deficiency was identified during a surveyor's review of the April 2024 MAR and discussed with the DON.
A facility failed to include catheter care in a resident's comprehensive care plan, despite physician orders and completed care documented in the Treatment Administration Record. The DON acknowledged the omission after reviewing the care plan.
A facility failed to adhere to a physician's orders for a resident with CHF, who required daily weights to manage fluid volume imbalance. The resident refused daily weights, and the physician agreed to change the order to weekly weights. However, the facility did not document this change, and the medical record incorrectly showed an order for monthly weights. The ADON confirmed the lack of documentation, and the physician later stated the order should have been for weekly weights.
A resident identified as a fall risk was repeatedly observed without the fall mat properly placed as per their care plan. Despite being at risk for falls, the fall mat was found folded and not in use on multiple occasions. A GNA acknowledged the oversight and corrected the placement after being prompted. The DON was informed of the issue.
Two residents in the facility were found to have inadequate catheter care. One resident's urine collection bag was observed on the floor, and their medical record lacked complete documentation of catheter size and balloon fluid amount. Another resident's Foley bag was repeatedly observed on the floor, despite staff acknowledging it should not be there. The DON was informed of these issues, which could lead to infection risks.
A resident's care was not properly overseen, as necessary A1C and TSH blood work were not completed in 2024 despite the attending provider's notes indicating the need for these tests. The facility lacked documentation of these tests being ordered or completed, and interviews revealed a lack of awareness and oversight regarding the resident's blood work orders.
The facility failed to ensure complete, accurate, and timely physician documentation for two residents. One resident's attending provider's notes were not part of the medical record and inaccurately reported stable blood sugar levels without testing. Another resident's medical record lacked documentation from the primary care provider for 2024, with no goal range for PT/INR results noted. Both cases involved late signing of notes, highlighting deficiencies in maintaining accurate medical records.
The facility failed to ensure nursing staff competency, as two RNs lacked competency evaluations. RN #19, hired in August 2024, and RN #3, an agency staff member since May 2023, had no records of evaluations. This was identified during a recertification survey, and the DON acknowledged the deficiency.
The facility was found deficient for not having a full-time Director of Nursing (DON) during a survey. The DON was also serving as the only Infection Preventionist (IP) nurse, which prevented her from fulfilling the full-time DON role. This dual role was acknowledged by the facility's administration as a concern, potentially impacting all residents, staff, and visitors.
A facility failed to ensure timely review and action on a pharmacist's medication regimen recommendation for a resident. The pharmacist suggested changing an antifungal cream to a barrier cream in May, but the attending physician did not sign off until September, and the change was not implemented until December. The facility's policy lacked a clear timeframe for addressing such recommendations.
Two residents received medications outside of prescribed parameters. One resident was given Morphine without documented pain levels, and another received Metoprolol and Spironolactone despite low blood pressure readings. The DON confirmed these findings.
The facility failed to properly document narcotic reconciliation, store medications according to standards, and ensure medications were not left unattended. A narcotic record book was incorrectly signed, expired medications were found in two medication carts, and an inhaler was not dated when opened. Additionally, a resident's medications were left at the bedside without a process to ensure they were taken. The DON acknowledged these issues.
The facility was found deficient in employing a qualified dietary staff, as the Director of Food Services is not yet certified and is currently enrolled in school to obtain the necessary credentials. The Clinical Dietitian, working remotely, confirmed her role does not include managing or supervising the kitchen.
The facility failed to employ a qualified social worker, monitor employee health status, provide the required bedside care hours, and ensure the Quality Assurance committee had the necessary members. The absence of a licensed social worker led to unqualified staff performing social work duties. Employee health records were incomplete, lacking necessary immunizations and TB tests. The facility also did not meet the required bedside care hours for 27 out of 60 days, and the Quality Assurance committee lacked attendance from key members.
The facility failed to maintain accurate and legible medical records for three residents. Medications were documented as administered without confirming ingestion, a change in condition note lacked physician response, and handwritten notes were illegible. These issues highlight deficiencies in record-keeping practices.
A facility failed to properly disinfect a glucometer between resident uses, risking the spread of infections. A nurse used the device on a resident without cleaning it and attempted to use it on another without disinfection. The DON, also the infection preventionist, was unsure of the correct disinfectant, which should have been Super Sani-Germicidal or Bleach Germicidal wipes, not alcohol wipes. Additionally, the facility's IPCP policies for Pneumonia, Influenza, and COVID-19 were outdated, not reviewed annually as required.
The facility failed to provide the 2024-2025 COVID-19 vaccine to five residents and four staff members. Despite requests from some residents, there was no documentation of the vaccine being administered or refused. The DON confirmed the lack of vaccination and was unable to provide necessary records, indicating a lapse in the facility's vaccination protocol.
A resident, dependent on staff for mobility and toileting, had their call device repeatedly placed out of reach, despite a care plan emphasizing its accessibility. The DON was aware of the issue and had conducted staff education, but the problem persisted, as observed by both an RN and a GNA who found the device on the roommate's nightstand or floor, confirming the deficiency.
A resident reported stolen items and suspected a staff member, but the facility failed to log the grievance or report the allegation to the state agency as required by their abuse policy. The NHA investigated but did not follow through with mandatory reporting, and the DON acknowledged the oversight.
A facility failed to report an alleged misappropriation of a resident's property to the Office of Health Care Quality. A resident reported stolen items and suspected a staff member, but the Nursing Home Administrator did not report the incident as required by facility policy. The Director of Nursing confirmed the failure to report to the state agency responsible for monitoring care quality.
A resident with diabetes was admitted to the facility with hospital discharge orders for insulin administration, which were not followed. The resident's blood glucose was significantly elevated, and the facility failed to administer Insulin Lispro as prescribed. The DON acknowledged the oversight and confirmed that the insulin order was not entered into the system correctly.
A resident admitted with a sacral ulcer did not receive adequate care as the facility failed to follow treatment recommendations. The resident's protein supplement was administered less frequently than ordered, and a heel wound was not documented upon admission. The sacral wound worsened due to insufficient dressing changes, highlighting a lack of adherence to prescribed wound care protocols.
Failure to Provide Commode When Bathroom Was Out of Order
Penalty
Summary
Failure to reasonably accommodate a resident’s toileting needs occurred when a resident with an ADL self-care deficit and a care plan intervention requiring assistance to the toilet/commode with maximum assistance of one staff was admitted to a room whose bathroom was out of order due to recent floor renovation. During review of a facility-reported incident alleging abuse/neglect, a GNA documented that while attempting to assist this resident to the bathroom, it was discovered that the resident’s bathroom was under construction, and a bedpan was provided instead. The care plan, initiated two days after admission, specified assistance to the toilet/commode, but no commode had been made available in the resident’s room while the bathroom was nonfunctional. In an interview, the DON stated that at the time of the resident’s admission the bathroom was out of order because the floor needed time to set after renovation, and acknowledged that a commode should have been available for the resident’s use while the bathroom was out of commission. These findings, based on record review and staff interview, show that the resident’s identified need for assisted toileting to a toilet/commode was not reasonably accommodated when only a bedpan was provided in the absence of an accessible bathroom or commode.
Failure to Notify Responsible Party of Change in Condition
Penalty
Summary
The facility failed to notify a resident’s Responsible Party (RP) of a change in condition when a new wound was identified. Record review showed that the attending physician had determined on 12/5/25 that Resident #96 was unable to comprehend and make medical treatment decisions, and the resident had an advance directive naming a healthcare power of attorney. On 12/10/25, a wound provider documented a new wound on the resident’s genitalia, and RN #34 also entered a change of condition note for this new wound. In the section of the note addressing notification of the resident representative, RN #34 documented that the resident, described as alert and oriented, refused to have family notified, stating that it was their genitalia and they did not want to tell them. During an interview, the DON confirmed that the RP should have been notified when the new skin condition was found and treatment was needed. These findings, based on record review of the complaint and facility-reported incident and interviews, showed that the facility did not ensure the RP was informed of the resident’s new wound and related treatment needs, despite the resident’s documented inability to make medical treatment decisions and the presence of a designated healthcare power of attorney.
Failure to Protect Residents From Verbal Abuse and Neglect by a GNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse and neglect by a Geriatric Nursing Assistant (GNA). According to the facility’s own investigation, an allegation that a GNA verbally abused and refused to provide care to a resident was substantiated. On the morning in question, a GNA asked a coworker to assist in repositioning the resident. As they entered the room, the resident stated that they had been asking for help to use the toilet for a long time and urgently needed to urinate to avoid wetting themselves and the bed. The assigned GNA responded that they were serving breakfast trays and told the resident to go ahead and urinate in the bed, stating they would clean the resident up later. The coworker then left to return to their own assignment and, upon returning later to pick up breakfast trays, the resident again reported needing help to use the bathroom, stating they badly needed to urinate and believed they had started to wet themselves. Additional statements in the investigation file from other residents described broader concerns with how the same GNA provided care and spoke to them. One resident reported that when they asked this GNA for anything and the GNA was in a bad mood, the GNA would become upset, say they hated their job, and the resident felt scared to ask for help. Another resident stated that the GNA would offer a bath, say they would return, and then not come back until the afternoon, and also told the resident they did not have time to change them and would do it later, causing the resident to be afraid to ask for things because they would be told no. A third resident reported that the GNA would say they would be right back in the morning but would not return until after lunch even though the resident was wet and dependent on staff for help, and also reported hearing another resident yell in pain during a bath while the GNA told that resident they did not have to bathe them and could be taken off the assignment. The coworker GNA confirmed the accuracy of their statement during an interview, and the facility’s investigation concluded that the allegation of verbal abuse and neglect was verified.
Failure to Timely Revise Care Plans After Changes in Condition and Falls
Penalty
Summary
The deficiency involves the facility’s failure to review, update, and revise residents’ care plans after changes in condition. For one resident, surveyors observed the resident in bed using oxygen and later confirmed through record review that the resident had a physician’s order for PRN oxygen at 2 L/min via nasal cannula and a subsequent order for continuous oxygen every shift. Despite these orders, oxygen use was not reflected anywhere in the resident’s care plan. In an interview, the DON acknowledged that the resident was new to oxygen use and agreed that the care plan should have been updated to address oxygen usage. For another resident, the deficiency centered on incomplete and delayed care plan revisions following falls. The resident was admitted in early February and experienced a fall from bed on 2/9, documented by an RN note stating that fall protocol was initiated. A fall-risk care plan had been initiated earlier in the month, and after the 2/9 fall, an intervention was added to monitor side effects of medication; however, the actual fall event and existing risk factors were not fully captured in that revision. A later care plan, initiated after a second fall, documented that the resident was at risk for falls related to history of falls, gait and transfer dysfunctions, fatigue or weakness, new environment, impaired safety awareness/cognition loss, and unsteady gait—conditions that were already present after the first fall. In an interview, the DON confirmed that the fall care plan revised on 2/10 did not capture the actual fall and that care plans are expected to be updated as needed after such events.
Failure to Maintain Continuous Ordered Treatment for Coccyx Wound
Penalty
Summary
The facility failed to provide treatment according to a resident’s wound care orders and plan of care for a coccyx wound. Record review showed that on 12/10/25 an order was written to apply skin guard ointment to the genital area and coccyx every day and evening shift for skin healing, and this was documented as completed on the evening of 12/10/25 and the morning and afternoon of 12/11/25 before being discontinued on 12/11/25. A new order effective 12/12/25 directed staff to apply skin guard to the genital area every day and evening shift for wound healing, but this order did not include treatment to the coccyx. No other coccyx wound treatment was ordered or documented from 12/12/25 through 12/16/25. A new coccyx wound order was not written until 12/17/25, directing staff to cleanse with wound cleaner, apply medi-honey to the wound bed, and cover with a border foam dressing as needed. During an interview on 3/24/26, the DON was informed of the gap in coccyx wound care orders and documentation between 12/12/25 and 12/17/25 and stated she would look for wound care documentation; no additional documentation was provided by the time of survey exit. The deficiency involved one resident reviewed for wound care whose coccyx wound lacked ordered and documented treatment for several days following a change in the treatment orders.
Failure to Administer and Document Psychotropic Medication as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered for one resident. Record review showed that this resident had a lorazepam order changed on 3/14/25 from every hour as needed to a scheduled twice-daily dose due to an increase in behaviors. On the same day, Depakote was ordered twice daily for behaviors and agitation. Review of the March 2026 MAR revealed that lorazepam doses were left blank, indicating they were not given, from the afternoon dose on 3/14/26 through the morning dose on 3/19/26, when the medication was discontinued in the afternoon. In contrast, Depakote was marked as not available only for the afternoon dose on 3/14/26 and then documented as administered as ordered on subsequent days. Progress notes documented multiple reasons for lorazepam not being given, including waiting for medication delivery on 3/16/26 and the prescription not being signed by the provider on 3/17/26 and 3/19/26. Additional progress notes on 3/17/26 at 11:36 AM and on 3/18/26 at 11:53 AM and 7:40 PM stated that lorazepam was given as ordered, but these administrations were not recorded on the MAR. During an interview, the DON explained that if a provider had not signed the medication order, the pharmacy would not release the medication, and acknowledged that the medication should have been given as ordered and that staff should have obtained the provider’s signature. No additional documentation was provided to reconcile the discrepancies between the progress notes and the MAR entries.
Failure to Accurately Dispense and Document Pain Medication Administration
Penalty
Summary
The facility failed to ensure accurate dispensing and administration of medications for a resident receiving comfort care for pain management. A physician's verbal order was given to administer 5 ml of Morphine every 3 hours and to discontinue all other medications. However, review of the narcotic count sheet revealed that nursing staff were administering only 0.25 ml per dose from the morphine solution, rather than the ordered 5 ml. This incorrect dosing occurred 22 times over a period of several days, involving multiple nurses. Additionally, documentation discrepancies were identified, as there was no evidence in the electronic medication administration record (eMAR) that the medication was administered on 5 out of the 22 occasions when it was pulled from the stock solution. All five undocumented administrations were recorded by an agency LPN. The Director of Nursing confirmed the lack of documentation for these administrations after reviewing the records and acknowledged the concern regarding the facility's failure to ensure accurate medication dispensing and administration.
Failure to Prevent Significant Medication Error in Pain Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors related to pain management. The resident, who was on comfort care, was prescribed morphine for pain relief. Initially, a verbal order was given for morphine 10mg/5ml, to be administered 5ml by mouth every 3 hours. This order was later discontinued the same day, and a new order for morphine 100mg/ml, to be administered at 0.25ml every 3 hours as needed, was entered. Despite the change, both morphine solutions were delivered to the facility, and nursing staff continued to use the discontinued 10mg/5ml solution, administering 0.25ml doses from it over a period of several days. A review of narcotic count sheets confirmed that the discontinued morphine solution was used 22 times by different nurses, instead of the newly ordered concentration. The Director of Nursing acknowledged that the discontinued medication should not have been delivered and that the nursing staff should have used the correct morphine solution as per the updated order. As a result, the resident received incorrect doses of morphine for pain management, and the facility did not prevent a significant medication error.
Failure to Notify Physician When Medication Held
Penalty
Summary
The facility failed to notify a resident's physician when doses of metoprolol, a blood pressure-lowering medication, were held due to low systolic blood pressure or low heart rate. Record review showed that the medication was withheld on multiple occasions in May 2025, as documented in the Medication Administration Record (MAR), but there was no evidence that the physician was informed of these occurrences. Both the Director of Nursing and the Regional Nurse confirmed, upon review of the MAR and nursing documentation, that there was no documentation of physician notification for the held doses.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of verbal abuse involving a resident. The investigation file included several resident interview statements, but none of these statements identified the interviewer or the date the interviews were conducted. Staff interview statements were also incomplete; one Geriatric Nursing Assistant (GNA) stated she was not assigned to the resident at the time, while the other did not clarify if she worked with the resident during the incident. Additionally, the investigation file did not include a list of staff who were working on the resident's unit on the day of the alleged incident, nor was there any documentation showing that abuse education was provided to staff following the event. The Director of Nursing confirmed that the investigation was not thorough.
Failure to Maintain Accurate Medical Records Following Resident Fall
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards of quality for one of seven facility-reported incidents reviewed during a complaint survey. Specifically, after a resident experienced an unwitnessed fall resulting in a left wrist fracture, the facility's investigation file contained two duplicate handwritten documents from the consultant orthopedic Physician Assistant. One document indicated the right wrist was affected, while the other indicated the left wrist, with both otherwise being identical. The presence of these conflicting documents created confusion regarding the accurate medical record for the resident's injury. Interviews with the DON and the Physician Assistant revealed uncertainty about who altered the documentation to correct the affected wrist from right to left. The DON acknowledged that the facility accepted and filed the document with the correction, despite not knowing who made the change. The Physician Assistant stated he did not amend the document or write an addendum in this case. The DON confirmed that the document was incorrectly amended and that this constituted a deficiency in maintaining accurate medical records.
Failure to Administer Ordered Medications and Treatments
Penalty
Summary
Surveyors identified that the facility failed to administer physician-ordered medications and treatments to three residents, as evidenced by a review of Medication Administration Records (MAR) and Treatment Administration Records (TAR). Specific missed medications included acetaminophen for chronic pain, levothyroxine for hypothyroidism, megestrol acetate for benign endometrial hyperplasia, and multiple scheduled doses of insulin and blood sugar checks for diabetes management. Additionally, a physician's order to maintain and monitor a chest port for signs of infection every shift was not followed for one resident. These omissions were confirmed by the Director of Nursing (DON) after a review of the records, with no documentation found to indicate the medications or treatments had been provided. The missed administrations occurred on multiple dates and shifts, affecting residents with chronic pain, diabetes, hypothyroidism, and a need for port maintenance. The surveyor discussed the findings with the DON, who acknowledged the lapses, and later with the Regional Director and Consultant RN, who were also made aware of the deficiencies. The report documents that the required medications and treatments were not given as ordered, and the necessary monitoring was not performed, as confirmed by facility leadership.
Urine Collection Bag Not Secured Off Floor for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with a Foley catheter was observed with their urine collection bag resting on the floor while sleeping in bed. The observation was made by surveyors, and the assigned Geriatric Nursing Assistant (GNA) confirmed the resident's identity and later acknowledged that the urine collection bag was on the floor. The GNA stated she was preparing to clean the resident at the time of the observation. A review of the resident's care plan indicated specific interventions for catheter care, including maintaining the catheter tubing and bag above the floor and below the level of the bladder, ensuring the tubing was free of kinks or occlusions, and securing the catheter with a leg strap if needed. Despite these documented interventions, the urine collection bag was not properly secured, resulting in noncompliance with the care plan and facility policy.
Failure to Document Comprehensive Pain Assessments and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to provide safe and appropriate pain management for residents requiring such services. Specifically, staff did not document the reasons for administering as-needed (PRN) pain medications, nor did they record comprehensive pain assessments that included the intensity, location, and description of pain. Additionally, non-pharmacological interventions (NPI) were not implemented or documented prior to administering pain medications, as required by facility policy and physician orders. For two residents reviewed, one received acetaminophen on multiple occasions with only the pain intensity recorded, lacking documentation of pain location, description, and use of NPI. Another resident was administered oxycodone and acetaminophen regularly, but the records did not consistently include pain assessments or documentation of pain characteristics and NPI. The DON confirmed that pain management should include assessment of location, intensity, description, and effectiveness, as well as the use of NPI, and acknowledged the documentation deficiencies upon review.
Failure to Discontinue Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident continued to receive an antiulcer medication at a total daily dosage of 60 mg, despite the attending provider's order to reduce the dose to 20 mg daily. The pharmacist had recommended a dose reduction after reviewing the resident's medication regimen, and the provider issued a new order to decrease the medication. However, review of the Medication Administration Record (MAR) showed that the resident was administered both the original 40 mg dose and the new 20 mg dose daily, rather than discontinuing the higher dose as ordered. The DON confirmed during interview that the staff failed to discontinue the 40 mg dose, resulting in a medication error.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) as part of its infection prevention and control program for residents with pressure ulcers. Specifically, during a wound care observation for a resident with an active wound and a history of pressure ulcers, staff did not adhere to EBP requirements by failing to wear protective gowns in addition to gloves. The medical record review for this resident did not show any physician order for EBP, nor was there documentation or care plan indication that EBP was being used or considered. Another resident requiring wound care also did not have documentation of EBP implementation or assessment in their record, and there was no signage at the resident's doorway indicating the need for EBP. The Director of Nursing confirmed that EBP should be implemented for residents with pressure ulcers and was made aware of the staff's failure to wear gowns during wound care and the lack of physician orders for EBP for both residents.
Failure to Monitor Dishwasher and Food Temperatures
Penalty
Summary
The facility failed to adequately monitor and document temperatures for both the dishwasher machine and certain food items, leading to deficiencies in sanitation and food safety. During a gastrointestinal outbreak, it was observed that the dish machine log had not been updated since January 3, 2025, indicating a lack of temperature checks for several days. This was confirmed during a kitchen tour on January 8, 2025, and discussed with the Nursing Home Administrator and the Director of Nursing. A follow-up on January 14, 2025, confirmed that the dishwasher eventually reached the required temperature of 180 degrees after several runs. Additionally, a review of food temperature logs for January 2024 revealed missing documentation for the temperatures of pureed and mechanical soft diets during dinner meals on three specific days. This was confirmed by the Regional Manager, highlighting a failure to ensure food safety standards were consistently met.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were accurately documented and reflected the residents' status. This was evident in four residents out of 35 reviewed during the survey. For Resident #60, the MDS assessment inaccurately recorded the resident as having natural teeth, despite observations and dental assessments indicating the resident was edentulous and wore dentures. Similarly, Resident #24's MDS assessment incorrectly documented the presence of natural teeth, contrary to the resident's statement and dental records showing edentulism. Resident #64's MDS assessments inaccurately recorded insulin use, while the resident was actually receiving Ozempic injections for diabetes, which is not insulin. The Director of Nursing (DON) confirmed these inaccuracies during interviews. Additionally, the facility failed to accurately document the presence of pressure ulcers for Resident #75. The Admission MDS assessment indicated two unstageable pressure ulcers were present upon admission, based on a wound specialist's note dated four days after admission. However, there was no documentation in the hospital discharge summary, facility nursing documentation, or primary care physician notes to support the presence of a heel wound upon admission. The MDS nurse acknowledged the discrepancy during a phone interview, but no additional documentation was provided to confirm the heel ulcer was present at the time of admission.
Deficiencies in Care Planning and Resident Participation
Penalty
Summary
The facility failed to ensure that a resident participated in the care plan process and failed to revise a resident's care plan. For one resident, the comprehensive assessment indicated a decline in functional abilities, including eating, mobility, and transfers, which was not reflected in the care plan. The resident required more assistance than previously documented, but the care plan was not updated to reflect these changes. The RN responsible for scheduling care plan meetings was not informed of the changes in the resident's condition, and the care plan meeting did not address the decline in the resident's abilities. Another resident did not participate in their care plan meeting due to a gastrointestinal outbreak in the facility. Although the resident's symptoms had resolved, and they were off contact isolation, they were not included in the meeting. The nurse manager confirmed that the resident and their representative were not part of the meeting, and the resident was not followed up with afterward, despite being capable of making their own decisions. The Director of Nursing acknowledged that the resident should have been part of the meeting once they were off isolation. The facility's process for updating care plans and involving residents in their care planning was inadequate, leading to deficiencies in the care planning process for these residents.
Deficiencies in Meal Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance to residents during meals and incontinence care, as evidenced by the lack of documentation and interviews with the Director of Nursing (DON). Resident #469, who required extensive assistance with eating, had missing documentation for meal percentages and fluid consumption for several days in May 2023. Similarly, Resident #74, who also needed extensive assistance with eating, had missing documentation for meal assistance on multiple days. Resident #270, with moderately impaired cognition, also lacked documentation for meal assistance on several days. The DON confirmed that the absence of documentation indicated a lack of care provided on those days. In addition to meal assistance deficiencies, the facility failed to provide incontinence care to residents who required it. Resident #60 was found in a soiled brief upon transfer to the emergency room, with documentation showing a lack of toileting hygiene care on specific days before the transfer. The DON confirmed that Resident #60 did not receive care the night and morning prior to the transfer. Resident #22 also reported being left soiled on certain days, and a review of complaints and documentation revealed multiple instances where toilet care was not provided. The deficiencies in providing assistance with activities of daily living (ADLs) were confirmed through interviews with the DON and reviews of documentation. The lack of documentation for meal assistance and incontinence care indicated that the necessary care was not provided to the residents, leading to the deficiencies identified during the recertification survey.
Deficiencies in Pain Management Documentation and Practices
Penalty
Summary
The facility failed to adequately document and manage pain for several residents, leading to deficiencies in pain management practices. Resident #24, who has been residing in the facility since 2015 with chronic pain conditions such as arthritis and neuropathy, received PRN pain medications without proper documentation of the reasons for administration, pain assessment details, or implementation of non-pharmacological interventions (NPIs) prior to medication. The resident's care plan required NPIs before administering PRN pain medication, but this was not followed, and the staff only provided NPIs if explicitly ordered by the attending provider. Resident #59, admitted in early 2024, was identified as having constant pain. Despite having routine and PRN orders for pain medications, there was no documentation of NPIs being attempted before administering PRN medications. The facility's policy required evaluation and documentation of NPIs before administering pain medication, but this step was not followed. The Director of Nursing acknowledged the lack of documentation and confirmed that NPIs should be the first step in pain management. Similarly, Resident #64, who suffered a crushing injury with paralysis, received PRN pain medication without documentation of NPIs being attempted beforehand. The facility's policy was again not adhered to, as the required steps for evaluating and documenting NPIs were not followed. The Director of Nursing confirmed the absence of documentation for NPIs and recognized the concern, indicating that a non-medicated approach should always precede medication administration.
Failure to Maintain Privacy for Residents with Urinary Catheters
Penalty
Summary
The facility failed to maintain the dignity of residents with urinary catheters by not ensuring that urine collection bags were kept in privacy bags. This deficiency was observed in two residents. For Resident #419, multiple observations were made over several days where the foley bag was seen without a privacy cover, either on the floor or attached to the bed rail, visible from the hallway. Staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), acknowledged the absence of a privacy cover during these observations. Similarly, Resident #64's urine collection bag was observed without a privacy cover during an initial tour of the facility, visible from the hallway. The Registered Nurse (RN) assigned to the unit confirmed the observation and subsequently applied a privacy bag. A review of Resident #64's medical record indicated a care plan for catheter care, which included positioning the catheter bag and tubing below the bladder level and away from the entrance room door. The Director of Nursing acknowledged the concern regarding the visibility of the urine collection bag from the hallway.
Failure to Provide Quarterly Financial Statements to Resident
Penalty
Summary
The facility failed to provide residents with quarterly statements in writing of their personal funds account managed by the facility. This deficiency was identified during a survey when a resident confirmed that they had not received a written quarterly statement of their account for a year, despite keeping money in the facility. The resident's medical record indicated that they were capable of making their own decisions, which should have ensured they received these statements. The Business Office Manager (BOM) admitted to hand-delivering quarterly statements to residents who could make their own decisions and discussing the statements with them. However, the BOM only made copies for residents who specifically requested them. During the survey, the BOM presented a quarterly statement for the resident, which was signed but did not confirm that a copy was provided to the resident. This oversight led to the deficiency, as the facility did not ensure that residents received their quarterly financial statements in writing as required.
Failure to Inform Resident of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident of their right to formulate an advance directive, as evidenced during a survey. The medical record review for a resident admitted in December 2024 showed that the resident was capable of making their own decisions. However, there was no documentation indicating that the resident had been informed of their right to create an advance directive or that they had one in place. The nurse manager, who was also acting as the social services designee, admitted during an interview that she only inquired if residents already had advance directives and did not discuss the option to create one if they did not. This oversight occurred after the facility lost their social worker, and the nurse manager took on additional responsibilities. The nursing home administrator expected staff to assist residents in establishing advance directives if needed, but this expectation was not met in this instance.
Failure to Notify Physician of Medication Holds
Penalty
Summary
The facility failed to notify the physician when a medication was held several times for low systolic blood pressure (SBP) in the case of Resident #44, who was being treated for cardiomyopathy with Metoprolol. The medication order specified that Metoprolol 50 mg should be administered twice daily unless the resident's pulse was less than 60 or the SBP was less than 100. Despite these parameters, the medication was held on multiple occasions in April 2024 due to low SBP or heart rate, but there was no documentation indicating that the physician was informed of these instances. The surveyor's review of the April 2024 Medication Administration Record (MAR) revealed several dates when the medication was withheld due to low SBP or heart rate, including instances on April 3, 6, 9, 10, 12, 13, 14, 16, 17, and 18. During an interview, the primary care physician confirmed that she expected to be notified via fax or phone call if medications were held due to vital signs outside of the prescribed parameters. The lack of communication with the physician regarding these medication holds was discussed with the Director of Nursing (DON) and highlighted as a deficiency in the facility's processes.
Failure to Include Catheter Care in Resident's Care Plan
Penalty
Summary
The facility failed to provide a person-centered comprehensive care plan for a resident with an indwelling Foley catheter. The deficiency was identified during a survey when it was found that the resident's comprehensive care plan did not include catheter care, despite physician orders indicating the need for maintaining a 16 French indwelling Foley catheter and providing catheter care every shift. The Treatment Administration Record showed that catheter care was being completed, but this was not reflected in the care plan. The Director of Nursing acknowledged the omission upon review of the care plan, confirming that it did not address the resident's catheter care needs.
Failure to Follow Physician's Orders for Resident Weights
Penalty
Summary
The facility failed to follow the physician's orders for monitoring the weight of a resident diagnosed with congestive heart failure (CHF). The care plan for the resident included an intervention of daily weights to manage potential fluid volume imbalance related to CHF. However, the resident refused daily weights, and the facility communicated with the physician, who agreed to change the order to weekly weights. Despite this agreement, there was no documentation in the medical record to indicate that the order was officially changed to weekly weights. Instead, the medical record showed an order for monthly weights, which was not consistent with the physician's response. The Assistant Director of Nursing confirmed the lack of documentation for the change to weekly weights, and the primary care physician later reiterated that the order should have been for weekly weights.
Failure to Properly Place Fall Mat for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that fall mats were properly placed for a resident identified as a fall risk. Resident #10, who has been residing in the facility since 2018, was observed multiple times with the fall mat folded and not in the designated position on the left side of the bed as per the care plan. On several occasions, the resident was found in bed without the fall mat in place, despite being identified as a fall risk in the most recent evaluation dated 12/30/24. During an observation, the resident was noted to be in a precarious position with their head hanging over the side of the bed, and the fall mat was still not in place. A Geriatric Nursing Assistant (GNA #4) acknowledged the oversight and repositioned the fall mat after being prompted. The Director of Nursing was informed of the repeated failure to utilize the fall mat correctly, and they acknowledged the concern.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and services for residents with indwelling catheters, as evidenced by observations and interviews. Resident #64 was observed with a urine collection bag lying directly on the floor, which was confirmed by RN #3. The resident's medical record lacked complete documentation regarding the catheter size and balloon fluid amount, which was only corrected after the surveyor's inquiry. LPN #5 confirmed the incomplete order and attempted to rectify it, but there was no documentation to verify the catheter size. The Assistant Director of Nursing confirmed the absence of documentation, and a statement was provided indicating an attempt to clarify the catheter size with Urology. Resident #419 was repeatedly observed with a Foley bag on the floor, despite being in bed or using a bedside table. The bag was observed on the floor multiple times over several days, and staff confirmed that it should not be on the floor. The Director of Nursing was informed of the frequent observations of the Foley bag on the floor, acknowledging that it could be a source of infection. These observations indicate a failure to maintain proper catheter care and documentation, potentially compromising resident safety.
Failure to Oversee Resident's Medical Care
Penalty
Summary
The facility failed to ensure that a resident's care was properly overseen by a physician, specifically in the management of their antidiabetic and thyroid medications. The resident, who had been living in the facility since 2015, did not have necessary A1C and TSH blood work completed in 2024, despite the attending provider's notes indicating the need for these tests. The provider's notes from June, July, and August 2024 mentioned the requirement for A1C blood work, but there was no documentation of these tests being ordered or completed. Interviews with the Director of Nursing and the medical director revealed a lack of awareness and oversight regarding the resident's blood work orders. The attending provider admitted to missing the orders for the resident's blood work and acknowledged the oversight in managing the resident's care. This deficiency was evident in the lack of documentation and follow-through on necessary medical tests for the resident, which were crucial for monitoring their health condition.
Incomplete and Inaccurate Physician Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that physician's notes were complete, accurate, signed, and dated at each visit for two residents. For Resident #24, the attending provider's visit notes from January to December 2024 were not part of the medical record at the time of the survey. Although the resident received regular visits from the attending provider, the progress notes were not signed at each visit and were only completed on January 12, 2025. Additionally, the notes inaccurately stated that the resident's blood sugar levels were stable, despite no orders or tests being conducted to verify this information. The attending provider admitted to documenting based on staff reports without reviewing the resident's blood sugar logs. For Resident #44, the medical record lacked documentation from the primary care provider for the entire year of 2024. The resident, who had a diagnosis of atrial fibrillation and was on Coumadin, required regular PT/INR tests, but there was no documentation of the goal range for these results in the provider's notes. The primary care physician's notes, faxed to the facility on January 14, 2025, contained lab values from before 2024 and were signed off on January 13, 2025, indicating a lack of timely and accurate documentation in the resident's medical record.
Lack of Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff were competent in their skill set, as evidenced by the lack of competency evaluations for two registered nurses. RN #19, who was hired in August 2024, and RN #3, an agency staff member hired in May 2023, both had no records of competency evaluations. This deficiency was identified during a recertification survey when the Director of Nursing (DON) was asked to provide competency evaluations for two randomly selected nurses. Upon review of staff documents, it was confirmed that there were no competency evaluations for these two RNs. The DON acknowledged the absence of these evaluations as a deficiency.
Deficiency in Full-Time Director of Nursing
Penalty
Summary
The facility was found to be deficient in having a Director of Nursing (DON) who worked on a full-time basis during a recertification survey. The deficiency was identified through interviews and record reviews. The DON confirmed that she was also serving as the only Infection Preventionist (IP) nurse, which resulted in her not being able to fulfill the role of a full-time DON. The dual role of the DON was acknowledged by the facility's administration as a concern, indicating awareness of the deficiency. This situation had the potential to impact all residents, staff, and visitors at the facility.
Delayed Response to Pharmacist's Medication Review
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) were reviewed and acted upon in a timely manner by the attending physician. This deficiency was observed in the case of a resident who had been residing in the facility since 2015 and was receiving multiple medications, including an antifungal cream for moisture-associated skin damage. The pharmacist recommended on 5/21/2024 that the antifungal cream be reviewed for possible change to a barrier cream, in line with the antibiotic stewardship program. However, the attending physician did not sign off on this recommendation until 9/25/2024, and the change in medication was not implemented until 12/11/2024. The facility's policy and procedure for MRR were found to be inadequate as they did not specify a timeframe for the attending physician to address the MRR recommendations. Although the Director of Nursing (DON) reported that the regional office advised that MRRs should be addressed within 30 days, the delay in addressing the pharmacist's recommendation for the resident's medication change exceeded this timeframe. The DON confirmed that the facility did not receive the signed report from the attending provider's office until 12/11/2024, which contributed to the delay in implementing the new order.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications, as evidenced by the administration of medications outside of prescribed parameters. Resident #59, who had been residing in the facility since early 2024, was observed to be in discomfort and declined an interview due to not feeling well. The resident had orders for Morphine Sulfate to be administered as needed for severe pain, with specific instructions for administration prior to dressing changes. However, the resident received Morphine on several occasions without documentation of the pain level, including an instance where it was administered for a pain level of 3, which was outside the prescribed parameters. The Director of Nursing (DON) confirmed these findings upon review. Additionally, Resident #44 had an order for Metoprolol to be held if the pulse was less than 60 or systolic blood pressure was less than 100. Despite this, the medication was administered when the resident's blood pressure was below the specified threshold on two occasions. Furthermore, Spironolactone was also administered when the resident's blood pressure was below the ordered parameter. The surveyor discussed these concerns with the DON, who was unable to provide additional documentation or information before the survey exit.
Medication Management Deficiencies
Penalty
Summary
The facility failed to accurately document the reconciliation of controlled medications and store medications according to professional standards. During an observation, a narcotic record book was found on a medication cart with a nurse's signature in the space designated for a later shift, indicating an incorrect documentation of the narcotic count. The Director of Nursing confirmed that the signature was incorrect as it was placed before the actual transfer of narcotics to another nurse. The facility's policy requires that both the oncoming and outgoing nurses count the narcotics together and document the count, which was not adhered to in this instance. Additionally, expired medications were found in two medication carts during inspections. The medications included Allergy Relief, [NAME]-Tussin DM, Oyster shell, Fish oil, Mucus relief, Vitamin C, Dulcolax, and Aspirin, all of which were past their expiration dates. Furthermore, an inhaler for a resident was not dated when opened, contrary to the instructions that require it to be discarded six weeks after opening or when the counter reads zero. The LPNs responsible for the carts confirmed the presence of expired medications and the lack of proper documentation for the inhaler. Another issue was observed with a resident's medications being left unattended at the bedside. A plastic medicine cup with pills was found on the resident's bedside table, and the medications were documented as given in the Medication Administration Record. The LPN stated that the resident takes the medications at their discretion, and the facility lacked a process to ensure the resident takes their medications. The Director of Nursing acknowledged the need for procedures to secure the resident's medications until they are ready to take them.
Deficiency in Qualified Dietary Staff
Penalty
Summary
The facility failed to employ a qualified dietary staff, specifically in the position of Director of Food Services. During an interview, the Director of Food Services revealed that she was currently enrolled in school to obtain the necessary certification for her role, indicating that she did not yet possess the required credentials. Additionally, the Clinical Dietitian, who began working remotely with the facility, confirmed that while she interacts with the kitchen staff regarding snacks, supplements, and menus for residents, she does not manage or supervise the kitchen. The Regional Manager of Food Services acknowledged the deficiency, noting that the Director of Food Services is expected to complete her certification by July.
Deficiencies in Staffing and Health Monitoring
Penalty
Summary
The facility was found to be non-compliant with state regulations due to the absence of a qualified social worker. Since November 2024, the facility has not employed a licensed social worker, and the duties have been performed by the Administrative Nurse and the Director of Nursing (DON). Interviews with staff confirmed that there was no social worker employed or contracted to provide oversight, which is a requirement under the State of Maryland Code of Regulations. The facility also failed to monitor the relevant health status of its employees as required by state regulations. During the survey, it was discovered that several employees lacked documentation of necessary immunizations and tuberculosis (TB) tests. Specifically, a registered nurse lacked evidence of varicella immunization, another nurse lacked evidence of TB tests, and a dietary aide lacked both TB tests and Hepatitis B immunization documentation. The DON confirmed the absence of these records, indicating a failure in monitoring employee health status. Additionally, the facility did not meet the required minimum of 3 hours of bedside care per occupied bed per day for 27 out of 60 days. The DON acknowledged this deficiency and confirmed that the facility was aware of the shortfall. Furthermore, the Quality Assurance committee did not have the required members attending meetings, with the social worker, dietician, and geriatric nursing assistant missing several meetings throughout the year. This lack of attendance was acknowledged by the Chief Operating Officer and the DON, failing to meet state requirements for the committee's composition.
Deficiencies in Medical Record Accuracy and Legibility
Penalty
Summary
The facility failed to maintain complete, accurate, and legible medical records for three residents. For one resident, medications were left at the bedside, and the LPN documented them as administered when they were brought into the room, without confirming ingestion. The DON acknowledged the lack of a process to verify when the resident took the medications, and the MAR inaccurately reflected the administration time. This discrepancy was against the facility's Medication Administration Policy, which requires medications to be administered within a specific timeframe and documented post-ingestion. Another resident's medical record showed a change in condition note that lacked the physician's response and notification to the responsible party. The note was closed by the DON without this critical information. Additionally, the paper chart for a third resident contained illegible handwritten notes by the primary care physician, which even the nursing staff could not decipher. These deficiencies highlight the facility's failure to ensure medical records are complete, accurate, and legible, as required by professional standards.
Inadequate Disinfection of Glucometer and Outdated IPCP Policies
Penalty
Summary
The facility failed to ensure proper disinfection of a glucometer between uses on different residents, which is crucial to minimize the risk of spreading blood-borne pathogens. During a recertification/complaint survey, a nurse was observed using a glucometer on a resident and then placing it back in the medication cart without disinfecting it. The nurse later attempted to use the same glucometer on another resident without cleaning it first. When questioned by the surveyor, the nurse used alcohol wipes to clean the device, although the facility's policy and manufacturer guidelines specified the use of Super Sani-Germicidal Disposable wipes or Bleach Germicidal wipes for effective disinfection. The Director of Nursing (DON), who also served as the facility's infection preventionist, was initially unsure about the appropriate disinfectant and had to verify the correct procedure. Additionally, the facility did not review and update its Infection Prevention Control Program (IPCP) policies and procedures annually, as required. During the survey, the DON provided outdated policies for Pneumonia, Influenza, and COVID-19, which had not been revised since 2022 and 2021, respectively. Despite being asked to provide evidence of annual updates, the DON confirmed that the facility had not updated these policies annually, indicating a lapse in maintaining current infection control standards.
Failure to Administer COVID-19 Vaccine to Residents and Staff
Penalty
Summary
The facility failed to provide the 2024-2025 COVID-19 immunization to both residents and staff, as evidenced by the survey findings. Five residents, including Resident #3, Resident #22, Resident #63, Resident #64, and Resident #269, did not receive or refuse the COVID-19 vaccine, despite some having requested it. Interviews with residents and reviews of their health records confirmed the absence of documentation regarding the administration or refusal of the vaccine. The Director of Nursing (DON) acknowledged the lack of vaccination for these residents and was unable to provide immunization records or declination forms. Similarly, the facility did not provide the COVID-19 vaccine to four staff members, identified as Staff #3, Staff #24, Staff #25, and Staff #26. A review of their immunization records showed no evidence of the vaccine being administered or refused. The DON confirmed that these staff members neither refused nor received the vaccine, and no further immunization evidence was available. This deficiency was identified during the recertification survey, highlighting a failure in the facility's vaccination protocol for both residents and staff.
Failure to Ensure Call Device Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call devices were kept within reach of a resident, specifically Resident #40, who had been residing in the facility since 2022. The resident was coded as dependent on staff for transfers and mobility and required substantial assistance for toileting hygiene, as per the Minimum Data Set (MDS) assessment. Despite having a care plan in place that emphasized the importance of keeping the call light within reach and encouraging its use for assistance, the call device was repeatedly found out of reach. On multiple occasions, the call device was observed on the roommate's nightstand or on the floor, making it inaccessible to the resident. The Director of Nursing (DON) was aware of the issue since October 2024 and had conducted staff education and random inspections to address the problem. However, the interventions were ineffective, as evidenced by the continued observations of the call device being out of reach. The Registered Nurse (RN #3) and a Geriatric Nursing Assistant (GNA #15) both confirmed the improper placement of the call device during their respective observations and took immediate action to secure it within the resident's reach. Despite these efforts, the deficiency persisted, indicating a failure in maintaining the resident's safety and ability to request assistance when needed.
Failure to Implement Abuse Policy for Misappropriation Allegation
Penalty
Summary
The facility failed to implement its abuse policy regarding the misappropriation of property for a resident who alleged theft. The resident reported that their items were stolen in December 2024 and suspected a staff member. Despite the resident filing a grievance, the facility's grievance log for December 2024 did not reflect this allegation. The Director of Nursing (DON) confirmed that the Nursing Home Administrator (NHA) investigated the allegation, but the facility's policy requiring the reporting of such allegations to the state agency was not followed. The NHA provided documents related to the investigation, including a hand-written statement from the resident and a typed witness statement. However, the NHA admitted to not reporting the misappropriation allegation to the state agency, as required by the facility's abuse policy. The DON acknowledged the facility's failure to implement their policy on abuse, neglect, mistreatment, and misappropriation of resident property, highlighting a significant oversight in handling the resident's grievance appropriately.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an incident of alleged misappropriation of a resident's property to the Office of Health Care Quality (OHCQ). This deficiency was identified during interviews and record reviews, revealing that a resident reported stolen items in December 2024 and suspected a staff member. The resident had filed a grievance with the facility. Despite the facility's policy requiring either the Nursing Home Administrator (NHA) or the Director of Nursing (DON) to report such allegations to the state agency, the NHA admitted to not reporting the incident. The DON confirmed the failure to report the misappropriation to OHCQ, which is responsible for monitoring the quality of care in Maryland's healthcare facilities.
Failure to Administer Insulin on Admission
Penalty
Summary
The facility failed to ensure essential care upon admission for a resident with diabetes, as evidenced by the lack of administration of prescribed insulin. Upon review, it was found that the resident's blood glucose level was significantly elevated at 361.0 mg/dL on the evening of their admission. The hospital discharge orders included specific instructions for insulin administration, which were not followed by the facility. The Medication Administration Record (MAR) lacked documentation of the administration of Insulin Lispro on the day of admission, despite the resident having received Insulin Glargine earlier that morning before transfer. Interviews with the Director of Nursing (DON) revealed that the facility did not correctly enter the insulin orders into their system, resulting in the omission of necessary medication. The DON acknowledged the oversight and stated that the expectation was for the nurse to contact the doctor if the blood glucose level exceeded 300 mg/dL. However, this protocol was not followed, leading to a failure in providing the required diabetic management for the resident upon admission.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services to promote the healing of pressure ulcers for a resident who was admitted with a sacral decubitus ulcer. Upon admission, the resident required assistance with movement and was incontinent of bowel, which increased the risk of skin breakdown. Despite the presence of a sacral ulcer noted in the hospital transfer summary, there was no documentation of a treatment or dressing change order for the sacral ulcer until four days after admission when the resident was seen by a wound specialist. The resident was prescribed a protein supplement, ProSource, to aid in wound healing, but there was conflicting documentation regarding the frequency of administration. The supplement was ordered to be given twice daily, but the Medication Administration Record showed it was only administered once daily for over a week. Additionally, the wound specialist identified a right heel wound that was not documented upon admission, and the treatment recommendations for this wound were not followed as prescribed, with dressing changes occurring less frequently than advised. The sacral wound was documented as worsening, and the treatment recommendations for both the sacral and heel wounds were not fully implemented according to the wound specialist's instructions. The sacral wound required twice-daily dressing changes, but the Treatment Administration Record indicated it was only changed once daily. These discrepancies in care and documentation contributed to the facility's failure to provide adequate pressure ulcer care and prevent further deterioration of the resident's condition.
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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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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