Lorien Nsg & Rehab Ctr Belair
Inspection history, citations, penalties and survey trends for this long-term care facility in Bel Air, Maryland.
- Location
- 1909 Emorton Road, Bel Air, Maryland 21015
- CMS Provider Number
- 215341
- Inspections on file
- 20
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Lorien Nsg & Rehab Ctr Belair during CMS and state inspections, most recent first.
A resident who was fully dependent on staff for self-care due to Multiple Sclerosis did not receive necessary ADL care during an evening shift. Despite being cognitively intact and assessed as needing total assistance, the assigned GNA failed to change the resident after a bowel movement, and this lapse was only discovered by the next shift when a strong odor was noted and the resident reported not being cared for.
A resident who was admitted without pressure ulcers developed a Stage III ulcer and a DTI. Despite wound care orders for the right heel and a recommendation for x-rays, staff did not administer the ordered treatments or complete the diagnostic testing before discharge, as confirmed by staff interviews and record review.
The facility failed to maintain proper cold holding temperatures and ensure the cleanliness and proper storage of food items, as observed during a recertification survey. The walk-in refrigerator's temperature exceeded the recommended 41°F on multiple occasions, and there were missing temperature records. Ice build-up was observed on ice cream tubs with damaged lids, and the freezers had significant ice accumulation. Additionally, the dishwashing machine's temperature logs were incomplete, with missing records for several mealtimes, and some rinse temperatures were below the required minimum.
The facility failed to develop comprehensive care plans for residents, including addressing depression and medication use for a resident, ensuring hearing aid accessibility for another, and providing specific care instructions for a nephrostomy tube and post-surgical care for others. These deficiencies were identified during a recertification survey and confirmed by facility staff.
A facility failed to report an allegation of neglect in a timely manner, where a resident was left unattended in bed without a call bell for several hours. The incident was reported to the Nursing Home Administrator but was not communicated to the Office of Healthcare Quality until eight days later, despite the resident expressing distress. Interviews confirmed the delay and acknowledged that intention is not required for reporting such incidents.
A facility failed to document the transfer of a resident, including the reason for discharge, in the medical record. The resident's record lacked a discharge note and details on how or when they left the facility. The Director of Social Services acknowledged the absence of documentation and later provided email evidence of a Notice of Medicare Non-Coverage issued in March, with discharge dates not recorded in the medical record.
A resident was found with their call bell on the floor, out of reach, during a survey. An LPN confirmed the observation and returned the call bell to the resident's bed. The resident's care plan required the call bell to be within reach and encouraged its use for assistance.
The facility failed to manage advance directives properly for three residents. One resident lacked a second certification of incapacity, another had no evidence of being offered an advance directive despite a MOLST form indicating otherwise, and a third resident's advance directive was not obtained until after surveyor inquiry, despite being admitted a month prior.
A facility failed to provide written notification to a resident and their representative about a hospital transfer for symptomatic anemia and GI bleed. The resident was informed verbally, but no written documentation was provided. Staff interviews confirmed that written notifications were not part of the facility's practice, indicating a systemic issue.
The facility failed to provide written notification of the bed-hold policy to two residents or their representatives upon hospital transfer. Despite verbal communication, there was no documentation of the policy being shared. Staff interviews revealed a misunderstanding of the notification process, assuming residents and families were already informed.
A resident's MDS assessments failed to accurately capture diagnoses of adjustment disorder with mixed anxiety and depressed mood or depression, despite being prescribed Sertraline for depression. Facility staff, including an LPN, UM, and MDS Coordinator, confirmed the oversight, revealing a lapse in the process for accurately coding resident diagnoses.
A resident at the facility for short-term rehab fell and sustained a fracture, but the care plan was not updated until weeks later. Interviews with staff revealed confusion over who is responsible for updating care plans. The DON acknowledged the issue, noting that fall risks are assessed and reviewed, but the care plan was not promptly revised.
A resident's hearing aids were not accessible, leading to communication difficulties and frustration. The resident, who was bed-bound, had not worn the aids for weeks and staff failed to assist or document their use. The aids were found locked in a nightstand, contrary to facility policy.
The facility failed to provide proper respiratory care for two residents, as observed during a survey. One resident had undated oxygen tubing and an empty humidifier, with no physician order or care plan for oxygen use. Another resident's oxygen equipment was not dated or maintained according to orders. The facility's policy required daily checks and refills, but these were not consistently followed, leading to deficiencies in care.
A facility failed to ensure pharmacist recommendations were acted upon and documented in a resident's medical record. A pharmacist's recommendation regarding the continued use of omeprazole was not reviewed or signed by the attending physician until prompted by a surveyor, indicating a lapse in addressing medication regimen reviews.
A facility failed to document the necessity for PRN Clonazepam for a resident with panic disorder. The resident received five PRN doses in May without corresponding documentation in the progress notes. Interviews with an LPN and the DON confirmed that the rationale for PRN medication should be documented, but this was not done for the resident's doses.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in care documentation. One resident's records inaccurately reflected participation in activities, while another's showed care activities documented at times when no staff were present. A third resident's medication administration was documented incorrectly. These issues highlight a failure to adhere to professional standards in documentation.
Facility staff failed to perform proper hand hygiene during dressing changes and medication administration, leading to deficiencies in infection prevention and control. An LPN did not sanitize hands between glove changes during a dressing change, and another LPN failed to do so during a nephrostomy tube site dressing change. Additionally, an LPN did not sanitize hands before and after administering an injection. These incidents were observed by surveyors and confirmed by the DON.
The facility failed to provide timely care to a resident, leaving them unattended for hours without access to a call bell, and did not check their tube feeding. Another resident's hand splint care lacked physician orders and documentation. These deficiencies highlight issues in staff communication, oversight, and documentation.
The facility failed to respond to call lights in a timely manner, with residents experiencing wait times ranging from 19 minutes to over an hour. Despite staff education and audits, the issue persisted, affecting residents' dignity and care needs.
The facility failed to protect two residents from mental and physical abuse by a GNA staff member. One resident reported being yelled at and having a call bell thrown at them, while another resident experienced rough handling during care, resulting in pain. The staff member involved had not completed annual abuse training since 2020 and was removed from the facility following the incidents.
A resident reported feeling neglected due to long call light response times, with waits of 30 to 50 minutes over 7 days. The facility's investigation was incomplete, failing to interview all relevant staff and other potentially affected residents. Despite staff education on call bell response times, subsequent audits showed continued delays.
The facility failed to provide adequate incontinent care for two dependent residents. One resident was left unchanged for several hours despite requesting assistance, while another resident's family found them with soiled briefs during visits. Documentation revealed multiple instances of missed care.
A resident admitted for rehab therapy developed a sacral wound that was not properly measured or managed by nursing staff. The wound worsened, leading to infection and the resident's eventual death from sepsis and sacral wound complications.
The facility failed to ensure that a nursing assistant was competent and had the necessary skill set to care for residents. The employee file of a GNA showed no evidence of competence assessment, and the staff member was hired as a nursing assistant in training before receiving her certification.
The facility failed to ensure that a GNA had completed required abuse training and competencies, as her file revealed she had not completed annual abuse training since 2020. The DON and Administrator were unaware of this lapse and were newly acclimating to the facility. The deficiency was identified following allegations of abuse and neglect.
Failure to Provide Required ADL Care to Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to provide necessary activities of daily living (ADL) care to a resident who was totally dependent on staff for self-care. The resident, admitted in 2017 with a diagnosis including Multiple Sclerosis, was assessed as cognitively intact and fully dependent for self-care according to the most recent MDS assessment. On the evening in question, the resident's nurse identified that the resident needed to be changed after a bowel movement and instructed the assigned geriatric nursing assistant (GNA) to provide care. However, the GNA did not perform the required care, only emptying the resident's urinary catheter and failing to recognize the need for further assistance. The lapse in care was discovered when the next shift's GNA entered the resident's room and noted a strong odor, with the resident reporting that the previous GNA had not provided the necessary care. Facility investigation and interviews confirmed that the resident did not receive the required ADL care during the 3 PM to 11 PM shift. The administrator acknowledged that staff failed to provide the needed care for the resident during this time period.
Failure to Provide Ordered Pressure Ulcer Treatments and Timely Diagnostic Testing
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for a resident who was admitted without any pressure ulcers. The resident developed an open area on the left buttock, which progressed to a Stage III pressure ulcer, and also developed a deep tissue injury (DTI) on the right heel. The wound nurse practitioner ordered specific treatments for the right heel, including cleansing with wound cleanser, application of skin prep twice daily, and use of offloading foam heel boots. Additionally, an x-ray of the left buttock and sacrum was recommended to rule out osseous changes. Despite these orders, a review of the resident's physician orders and treatment administration records revealed that the right heel DTI treatments were neither ordered nor administered from the time of the initial wound nurse practitioner's order through the resident's discharge. Furthermore, the x-ray recommended by the wound nurse practitioner was not completed prior to discharge, with the order for the x-ray not being placed until several days after the recommendation. These failures were confirmed through interviews with facility staff, including the x-ray staff and the Director of Nursing.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility staff failed to maintain proper cold holding temperatures and ensure the cleanliness and proper storage of food items, as observed during a recertification survey. The surveyor noted multiple instances where the walk-in refrigerator's temperature exceeded the recommended 41°F, with specific dates showing temperatures as high as 45°F. Additionally, there were missing temperature records for several days in May 2024. Ice build-up was observed on ice cream tubs with damaged lids, and the freezers had significant ice accumulation. Despite a recent local health inspection that identified similar issues, the facility continued to experience elevated temperatures and missing documentation. The facility also failed to monitor the dishwashing machine's sanitation levels consistently. During a follow-up inspection, it was found that the dishwashing machine's temperature logs were incomplete, with missing records for several mealtimes. On some occasions, the recorded rinse temperatures were below the required minimum of 180°F. The Food Service Director acknowledged the missing documentation and attempted to fill in some temperatures after questioning a dietary worker. These deficiencies indicate a lack of consistent monitoring and documentation of critical food safety and sanitation practices.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and initiate comprehensive person-centered care plans for several residents, as identified during a recertification survey. For Resident #70, the care plan did not address the diagnoses of depression and adjustment disorder with mixed anxiety and depressed mood, nor did it include the use of an antidepressant medication, Sertraline. This oversight was confirmed by both the Licensed Practical Nurse and the Unit Manager, who acknowledged the absence of focus, goals, or interventions related to the antidepressant medication in the care plan. Resident #46 experienced issues with hearing aid accessibility, which was not adequately addressed in their care plan. Despite the resident's admission records indicating the presence of hearing aids, the care plan was incomplete and lacked necessary interventions. The Minimum Data Set nurse confirmed that care planning should have been completed, but it was only initiated after the surveyors began their investigation, more than 14 days post-admission. For Resident #54, the care plan lacked specific instructions for the care of a nephrostomy tube, site, and urine collection bag, despite the resident having returned from the hospital with these needs. The Director of Nursing confirmed the absence of these care instructions. Similarly, Resident #90's care plan did not reflect necessary interventions for post-surgical care following a left hip fracture, including anterior hip precautions and other post-surgical care requirements. The care plan was only revised after surveyor intervention, and even then, it did not comprehensively cover all necessary care interventions.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of neglect and the subsequent investigation to the proper authorities. This deficiency was identified during a recertification survey, where it was found that an incident involving a resident being left lying flat in bed, uncovered, and without a call bell within reach was not reported to the Office of Healthcare Quality until eight days after the occurrence. The incident was initially reported by the Social Worker to the Nursing Home Administrator on the day it occurred, but the facility delayed reporting it to the authorities, despite the resident expressing distress over the situation. During interviews, the facility's Director of Nursing and Administrator confirmed the delay in reporting and acknowledged that the incident did not need to be intentional to warrant reporting. The Geriatric Nursing Assistant assigned to the resident on the day of the incident confirmed that the resident was upset and had been left unattended for several hours. The facility's process for reporting allegations of abuse and neglect was described as immediate, yet this incident was not reported in a timely manner, leading to a deficiency in the facility's compliance with reporting requirements.
Failure to Document Resident Transfer
Penalty
Summary
The facility failed to document the transfer of a resident, identified as Resident #166, in the medical record, including the reason for the transfer. This deficiency was identified during a complaint intake review, medical record review, and staff interview. The resident's closed medical record was reviewed, revealing that there was no discharge note indicating the reason for the discharge or details on how or when the resident left the facility. Additionally, the discharge instructions document in the electronic health record was incomplete, lacking information on who received the instructions. The Director of Social Services, identified as staff #21, was interviewed and acknowledged the absence of documentation regarding the discharge. She could not recall the circumstances surrounding the initiation of the discharge and agreed that documentation should have been recorded. She later provided email documentation indicating that the resident was issued a Notice of Medicare Non-Coverage in March 2023, with a discharge initially set for March 6, 2023, and later extended to March 7, 2023. However, this information was not included in the resident's medical record, highlighting the incomplete discharge documentation.
Resident's Call Bell Out of Reach
Penalty
Summary
The facility failed to ensure that a resident had access to their call bell to request staff assistance. During an initial tour, a surveyor observed the resident lying in bed with the call bell on the floor, out of reach behind the bed. This observation was confirmed by an LPN, who then retrieved the call bell and clipped it to the resident's bed. A review of the resident's medical record revealed a care plan intervention dated March 5, 2024, which specified that the call bell should be kept within reach and that the resident should be encouraged to use it for assistance, along with having commonly used articles within reach.
Deficiencies in Advance Directive Management
Penalty
Summary
The facility failed to ensure proper certification of incapacity for Resident #90, as only one certification was present in the medical record, despite the requirement for two certifications by the attending and a second physician or licensed clinical psychologist. The Maryland Order for Life Sustaining Treatment (MOLST) form indicated that the resident or authorized decision maker had declined to discuss or was unable to make a decision about treatments. The Unit Manager confirmed the absence of the second certification, and the Director of Social Work acknowledged the oversight after surveyor intervention. For Resident #54, there was no evidence of an advance directive or that one had been offered, despite a MOLST form indicating a decision per the resident's advance directives. The social services designee confirmed that advance directive information should be in each resident's chart and that discussions should be documented. However, there was no previous documentation of any discussion with the resident regarding advance directives, and the resident had been at the facility for two years without any evidence of being asked or provided information about advance directives. Resident #112's medical record lacked a copy of the advance directive upon admission. The social worker's notes indicated that the resident had an advance directive and suggested contacting a family member. The Director of Nursing later provided a copy of the advance directive after the surveyor's request, confirming that it was obtained from the resident's family member after the surveyor's inquiry, despite the resident being admitted about a month prior.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their representative regarding the reason for a transfer to the hospital. This deficiency was identified during a recertification survey for a resident who was hospitalized for symptomatic anemia and a gastrointestinal bleed. The resident confirmed that they were informed verbally about the transfer but did not receive any written documentation. A review of the medical records and interviews with staff, including the Director of Nursing and the Nursing Home Administrator, revealed that there was no evidence of written notification being provided to the resident or their representative. Further interviews with facility staff, including a Licensed Practical Nurse and a Unit Manager, confirmed that it was not the practice to provide written notifications for hospital transfers. Instead, the reasons for transfers were communicated verbally to residents and their representatives, and documented in the transfer sheet sent to the hospital. This practice was consistent among the staff interviewed, indicating a systemic issue in the facility's process for notifying residents and their representatives in writing about hospital transfers.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to notify residents or their representatives in writing about the bed-hold policy upon transfer to an acute care facility. This deficiency was identified during a recertification survey for two residents who were hospitalized. The bed-hold policy outlines the facility's procedure for reserving a resident's bed during their absence for therapeutic leave or hospitalization. However, the facility did not provide written notification of this policy to the residents or their representatives. In the case of one resident, they were transferred to a hospital for symptomatic anemia and a gastrointestinal bleed. Although the resident was verbally informed about the transfer, there was no written documentation provided regarding the bed-hold policy. The Director of Nursing (DON) confirmed the absence of such documentation and acknowledged that the staff failed to complete the relevant section of the change in condition form. Interviews with staff members revealed a lack of understanding and execution of the policy, as they assumed residents and their families were already aware of it. For another resident, who was transferred to the hospital following a fall, neither the resident nor their representative received the bed-hold policy. The documentation indicated that the policy was included in the transfer package given to emergency medical technicians, but not directly to the resident or their family. The DON and Nursing Home Administrator were unable to provide evidence of communication with the resident or their representative regarding the bed-hold policy, highlighting a systemic issue in the facility's notification process.
Inaccurate MDS Coding for Resident's Psychiatric Diagnoses
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident during a recertification survey. The resident, who was admitted with diagnoses including adjustment disorder with mixed anxiety and depressed mood, was prescribed Sertraline for depression. However, the MDS assessments did not capture the diagnosis of adjustment disorder with mixed anxiety and depressed mood or depression under the psychiatric/mood disorder section, despite the medication being recorded in the medication section. This discrepancy was identified through a review of clinical records, physician orders, and medication administration records. Interviews with facility staff, including a Licensed Practical Nurse (LPN), Unit Manager (UM), MDS Coordinator, and Director of Nursing (DON), confirmed the oversight. The MDS Coordinator acknowledged the error, stating that the expectation was to review active diagnoses within a 60-day period and ensure they were active during the 7-day assessment reference date look-back period. The DON and Nursing Home Administrator were unaware of the omission in the MDS assessments, indicating a lapse in the facility's process for accurately capturing resident diagnoses.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident after the resident sustained an injury from a fall. The resident, who was at the facility for short-term rehabilitation due to a respiratory infection, experienced a fall resulting in a fracture and was subsequently hospitalized. Upon returning to the facility, the resident's care plan, which initially included a goal to prevent falls, was not updated to reflect the new circumstances and necessary interventions until several weeks later. Interviews with nursing staff revealed a lack of clarity and responsibility regarding the updating of care plans. Night shift staff indicated that they do not initiate or update care plans, suggesting that this responsibility lies with supervisors. The Director of Nursing and Nursing Home Administrator acknowledged the issue, noting that fall risks are assessed upon admission and reviewed weekly, but the care plan for this resident was not promptly revised following the fall. The management team, including the Assistant Director of Nursing and the Minimum Data Set coordinator, is responsible for care plan updates, but the process failed in this instance.
Hearing Aid Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's hearing aids were accessible, leading to the resident's inability to hear properly. During an observation, the resident was found not wearing hearing aids and expressed difficulty in hearing conversations, which caused frustration. The resident indicated that the hearing aids were somewhere in the room but was unsure of their exact location and mentioned that staff did not assist in accessing them. The resident had not worn the hearing aids for several weeks, and the Treatment Administration Record (TAR) lacked any instructions or care information regarding the hearing aids. Further investigation revealed that the resident was bed-bound and unable to independently retrieve items from the room. The hearing aids were eventually found locked in the nightstand, which the resident could not reach. The facility's hearing aid policy required staff to assist residents with hearing aids and document their use and care, but this was not followed. The Licensed Practical Nurse (LPN) assigned to the resident was unaware of the resident's hearing impairment, and the Director of Nursing (DON) acknowledged the issue when informed by the surveyor.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents during a recertification survey. For one resident, oxygen tubing was found disconnected and undated, with an empty humidification water bottle. The resident's medical records lacked a physician's order for oxygen and did not include oxygen use in the care plan. The Director of Nursing (DON) later confirmed that the oxygen order was missing when the resident returned from the hospital, and the care plan was not updated to reflect oxygen use until after the surveyor's observation. Another resident was observed with a nasal cannula connected to an empty humidifier bottle, which was dated two weeks prior, and undated oxygen tubing. The Licensed Practical Nurse (LPN) confirmed the discrepancies and adjusted the oxygen flow to the correct setting. The resident's medical records showed an active physician order for oxygen therapy, but the care plan did not include instructions for changing and dating the oxygen equipment weekly, as indicated in the physician's order and Treatment Administration Record (TAR). The facility's policy on oxygen administration required daily equipment checks and refilling of humidifiers when water levels were low. However, the observations revealed that these procedures were not consistently followed, leading to deficiencies in the respiratory care provided to the residents. The DON acknowledged the issues and stated that nurses were responsible for replacing empty humidifiers and that care plans should reflect physician orders, although this was not always the case.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility staff failed to ensure that pharmacist recommendations were acted upon and documented in the resident's medical record, as evidenced during a recertification/complaint survey. Specifically, for one resident, the monthly medication regimen review with consultant pharmacist recommendations to the physician was not readily found in the medical record. The Director of Nursing (DON) confirmed that there were no pharmacist recommendations documented for several months, and although a recommendation was made in January, it was not addressed until prompted by the surveyor. The pharmacist's recommendation involved the continued use of omeprazole, a proton pump inhibitor (PPI), which requires a documented review after 12 weeks of use due to potential risks. The recommendation was not reviewed or signed by the attending physician until the surveyor requested it, indicating a lapse in the facility's process for addressing pharmacist recommendations. The DON acknowledged that the recommendation was missed and had to be addressed retroactively.
Failure to Document PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to adequately monitor and document the necessity for the use of PRN (as needed) psychotropic medication for a resident. Specifically, Resident #112 was prescribed Clonazepam for panic disorder, with both routine and PRN doses. During May 2024, the resident received five PRN doses of Clonazepam. However, there was no documentation in the resident's medical records or progress notes to justify the administration of these PRN doses, indicating a lack of proper assessment and documentation of the resident's behavior or condition that warranted the additional medication. Interviews with facility staff, including an LPN and the DON, revealed that the standard procedure was to document the rationale for administering PRN psychotropic medications in the progress notes. The LPN stated that mood and behavior concerns like agitation would prompt the administration of medication, which should be documented accordingly. The DON confirmed that the rationale for PRN medication should be documented, and acknowledged the surveyor's findings that such documentation was missing for Resident #112's PRN Clonazepam doses.
Inaccurate Medical Records and Care Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care documentation. For one resident, the medical records inaccurately reflected participation in activities, despite observations and staff interviews indicating that the resident was often in bed and not engaged in the documented activities. Staff interviews revealed inconsistencies in the reported activities, with some staff unaware of any activities being offered to the resident in their room. Another resident's medical records showed discrepancies in the documentation of care provided. The records indicated that an LPN documented care activities, such as enteral tube assessments and repositioning, at times when camera footage confirmed no staff were present in the resident's room. The facility's investigation into an incident where the resident was left without access to a call bell and in the same position overnight was deemed inconclusive, but it was confirmed that care was not provided during the night shift. For a third resident, an LPN documented administering an inhaler at a specific time, but later admitted to administering it at a different time. This discrepancy was confirmed during an interview with the DON, who acknowledged the incorrect documentation. These inaccuracies in medical records highlight a failure to adhere to professional standards in maintaining accurate and reliable documentation of resident care.
Deficiencies in Hand Hygiene During Care Procedures
Penalty
Summary
The facility staff failed to ensure proper hand hygiene during dressing changes and medication administration, leading to deficiencies in infection prevention and control. During an observation, an LPN did not perform hand hygiene after removing dirty gloves and before donning clean gloves while changing a resident's left heel ulcer dressing. The LPN acknowledged the oversight and confirmed awareness of the proper procedure. Similarly, another LPN failed to perform hand hygiene between glove changes during a nephrostomy tube site dressing change for a resident, admitting a lack of knowledge about the requirement. Additionally, a third LPN did not sanitize hands before and after administering a subcutaneous anticoagulant injection to a resident. The LPN admitted to not following the handwashing protocol, which was confirmed by the Infection Preventionist. These incidents were observed and reported by surveyors, and the Director of Nursing validated the concerns, highlighting a pattern of non-compliance with hand hygiene protocols among the nursing staff.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide timely and necessary care to Resident #3, as evidenced by two self-reported incidents. The first incident occurred on 5/9/24, when Resident #3 was left lying flat in bed without their call bell in reach for an extended period. The facility's investigation revealed that no staff rounded on the resident for approximately three hours and forty minutes. Despite this, the investigation was deemed inconclusive. Interviews with staff indicated that the resident was upset by the incident, and there was a lack of communication and documentation regarding the resident's needs and care. The second incident involving Resident #3 occurred on the night of 5/11/24 into 5/12/24. The resident was reportedly left in bed from 6 PM to 6:30 AM without access to their call bell and without being repositioned. The facility's investigation confirmed that no staff entered the resident's room during this time, and the resident's tube feeding was not checked. The facility's documentation was incomplete, and there was no process in place to ensure that resident complaints were documented in their medical records. Additionally, the facility failed to have accurate physician orders for Resident #71's hand splint. Although a sign above the resident's bed indicated the use of a hand splint, there were no physician orders or documentation of the resident's use and response to the splint. The Director of Nursing confirmed that there should have been an order and care documentation for the resident's splint care, but it was not present in the medical records.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence by not responding to call lights in a timely manner. Resident #30 reported an allegation of abuse due to long wait times for call light responses, ranging from 30 to 50 minutes over a week. This resident, who had a stroke and required assistance for toileting, expressed concerns about urinary tract infections and skin problems from prolonged exposure to wet briefs. Despite the facility's expectation of a 10-15 minute response time and subsequent staff education, the issue persisted without effective auditing or follow-up to ensure compliance. An anonymous complaint and grievances from two other residents further highlighted the problem. One resident reported call light response times of over an hour, while another, who was on Lasix and experienced urinary urgency, waited between 19 to 50 minutes for assistance. The facility's audits confirmed these extended wait times, but there was a failure to investigate the root causes and implement appropriate corrective actions. The DON and NHA acknowledged the issue but did not take sufficient steps to address it effectively.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from mental and physical abuse. This was evident during the review of two residents. One resident reported that after using the call bell for assistance to use the bathroom, a GNA staff member threw the call bell at them and yelled not to press the button again. The resident, who had mixed incontinence and moderate cognitive impairment, reported feeling fearful and refrained from using the call bell for the remainder of the shift. The resident later stated that they now feel safe and are happy with the care they receive. Another incident involved the same GNA staff member who turned a resident 'roughly' during activities of daily living care, causing the resident to verbalize discomfort. The resident, who had severe cognitive impairment, was assessed for pain in their right arm and shoulder, and an x-ray was ordered. Although the x-ray results were negative, the resident was medicated with Tylenol for pain. The facility's investigation confirmed the staff member's actions, and the staff member was removed from the facility. A review of the staff member's file revealed that they had not completed their annual abuse training since 2020.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of neglect reported by a resident who felt neglected due to staff not responding to the call light. The review of the facility's call light audit revealed that the resident had waited 30 to 50 minutes for call light responses over a period of 7 days, during all three shifts. Although the facility staff interviewed the Geriatric Nursing Assistants (GNAs) assigned to the resident during the long call light response times, they did not interview the nurses and other GNAs assigned to the unit to determine their activities during those times. Additionally, the facility failed to interview other residents who might have been affected by the extended wait times. An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) revealed that the facility had not conducted a comprehensive investigation. The DON admitted uncertainty about whether other staff assigned during the extended wait times had been interviewed. Despite the education provided to staff regarding call bell response time expectations, a subsequent audit showed that residents continued to wait 30 to 64 minutes for responses to call bells. The facility did not audit call bell response times following the education to determine its effectiveness.
Failure to Provide Incontinent Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate incontinent care for two dependent residents. Resident #6 complained to the social worker about a GNA who failed to change them after promising to return. The resident was left unchanged from 7 PM until 3 AM the next day, when a nurse finally attended to them. The GNA involved was subsequently taken off the schedule and reported to the Board of Nursing for neglect. Resident #39, admitted for rehab after a hospital stay, was found by family members with soiled briefs during their evening visits. The resident complained that their call bell requests for assistance were ignored. A review of the resident's kardex revealed multiple instances where incontinence care, mobility assistance, and bathing were not documented or provided. The administrator and Director of Nursing were informed of the missing documentation, but they were not working at the facility during that period.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers. Resident #39 was admitted for rehab therapy with no initial wounds on their sacrum. However, a new open area was discovered on the sacrum, and nursing staff failed to obtain wound measurements at the time of discovery. The wound worsened, showing signs of infection, including foul-smelling drainage and discoloration, yet measurements were still not recorded. The resident was eventually sent to the hospital due to a change in mental status and lethargy and subsequently died from sepsis and sacral wound complications.
Failure to Ensure Competence of Nursing Assistant
Penalty
Summary
The facility failed to ensure that nursing assistants were competent and had the necessary skill set to care for the residents. This was evident for one nursing assistant staff member. On 4/8/24, the Director of Nursing (DON) and Nursing Home Administrator (NHA) reviewed the employee file of Geriatric Nursing Assistant (GNA) Staff #22 and found no evidence that the facility had determined her level of competence. The DON and NHA confirmed that there was no additional paperwork to demonstrate Staff #22's competence. Further review revealed that Staff #22 was hired in October 2022 as a nursing assistant in training and did not receive her GNA certification until May 2023. The concern was discussed with the DON and NHA on 4/9/24.
Failure to Ensure Abuse Training and Competencies for GNA
Penalty
Summary
The facility failed to ensure that geriatric nursing assistants (GNA) had the required abuse training and competencies to provide safe and proper care to residents. Specifically, the employee file of GNA #17 revealed that she had not completed her annual abuse training since 2020. This deficiency was identified during a review of complaints, facility-reported incidents, interviews, and employee files. The Director of Nursing (DON) and Administrator were unaware of the lapse in training and were newly acclimating to the facility. The employee's file was reviewed following allegations of abuse and neglect, leading to the implementation of education and inservices for other employees related to the findings from the incidents.
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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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