South River Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Edgewater, Maryland.
- Location
- 144 Washington Road, Edgewater, Maryland 21037
- CMS Provider Number
- 215297
- Inspections on file
- 20
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at South River Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Surveyors found that the facility did not complete accurate MDS assessments for three residents. One resident admitted with a shoulder fracture from a fall at home was incorrectly coded on the 5-day MDS as having two in-facility falls, including one with major injury, even though the DON confirmed no falls occurred after admission. Another resident who had two documented falls in the facility had those events correctly coded on an End of PPS Part A Stay MDS, but the same two falls were inappropriately re-coded as new events on a later discharge MDS despite no additional falls. A third resident’s Quarterly MDS was coded to show seven days of insulin injections in Section N0350, although the EMR contained no insulin orders; the MDS Coordinator stated Ozempic had been mistakenly coded as insulin.
A resident was transferred from one room and nursing station to another, but there was no documentation in the medical record that the resident or responsible party was notified of the room change. During interviews, the DON acknowledged that facility expectations require notification and documentation of room changes, yet no record of such notification could be found or produced to surveyors.
The facility failed to maintain a safe and homelike environment, with issues such as damaged baseboards, stained ceiling tiles, and exposed pipes. Additionally, a resident's personal property was not adequately protected from wandering residents, leading to broken and missing items. The resident, who was alert and oriented, expressed ongoing concerns about safety and security.
The facility failed to protect residents from abuse in two incidents. In one case, a resident was found undressing and inappropriately touching another resident, leading to police involvement and arrest. In another incident, two residents were found intertwined, resulting in one being pushed and falling. Both cases highlight the facility's inability to maintain a safe environment.
The facility failed to provide necessary personal hygiene care for two residents dependent on staff for assistance with ADLs. One resident with an ileostomy did not receive documented ostomy care until weeks after admission, and another resident had unkempt toenails that were only addressed after a complaint. Both residents were documented as needing significant assistance with personal hygiene, highlighting a deficiency in care.
A resident fell off the bed while a GNA was providing incontinent care, despite the care plan requiring two people for repositioning. The resident, who was dependent and required assistance for toileting hygiene, was evaluated at a hospital with no injuries found. The DON confirmed only one GNA was present during the incident.
A resident with a history of traumatic brain injury and severe spasticity experienced inadequate pain management due to the facility's failure to monitor and assess an intrathecal baclofen pump. The nursing staff lacked training on the pump's care, leading to insufficient documentation and oversight of the pump's function and effectiveness.
A facility failed to ensure accurate documentation and review of a resident's care plan after a visit. The resident, who had a PEG tube, had medication orders that were not updated to reflect the change from oral to PEG tube administration. Both the NP and Physician documented incorrect medication routes, and the DON could not confirm the correct administration route. The MD acknowledged an oversight in the medication administration route.
Surveyors found that the facility failed to maintain an effective pest control program, as evidenced by the presence of gnats in various areas, including resident care areas and the kitchen. Despite reports of gnats from 2017 to 2022, there was no documentation of resolutions. The Maintenance Director confirmed the issue but could not provide documentation of treatment or prevention efforts.
A facility failed to maintain a dignified environment for a resident by continuing to use a plastic bag to line the commode after the resident was cleared from a stomach infection. Staff interviews revealed uncertainty and continuation of the practice without necessity.
A facility failed to ensure a resident's call bell was within reach, as observed during a survey. On multiple occasions, the call bell was found on the floor, out of reach. A GNA and an LPN confirmed the issue and placed the call bell back within reach. The RN Unit Manager and DON acknowledged the facility's policy that call bells should always be accessible.
The facility failed to document whether a resident had an advance directive upon admission and did not ensure the accuracy of another resident's MOLST form. One resident's medical record lacked documentation of an advance directive, and the DON confirmed the absence due to the resident's inability to make decisions. Another resident's MOLST form had a blank decision-making section, despite an advance directive on file, which was acknowledged as an omission by the DON and Administrator.
The facility failed to notify two residents and/or their representatives of the bed hold policy upon hospital transfer. In one case, a bed hold was initiated without documented communication, and in another, the representative was not informed for a subsequent transfer. The Admissions Director acknowledged the oversight and has since been notifying all parties for hospital transfers.
The facility failed to accurately document MDS assessments for two residents, leading to deficiencies in their medical records. One resident with a colostomy was incorrectly coded as having no appliances, while another resident on hospice was inaccurately documented as not receiving hospice services. The MDS Director acknowledged these errors during interviews with surveyors.
A facility failed to conduct a new PASARR Level I screening after a resident was diagnosed with bipolar disorder during their stay. Initially, the resident was admitted with a PASARR Level I screening that did not indicate the need for a Level II evaluation. The deficiency was identified during a recertification survey, and the facility's staff acknowledged the oversight.
A facility failed to include dietary and nutritional needs in the baseline care plan for a resident with a complex medical history, including congestive heart failure and dementia. The omission was identified during a review of the resident's records, which showed that while other care plans were initiated, the dietary plan was not included within the required 48-hour timeframe.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a urinary device lacked a corresponding care plan, another resident had a missing lens in their glasses with no action taken, and a third resident with a colostomy did not have a care plan for colostomy care. Interviews with staff confirmed these oversights.
A facility failed to update a resident's care plan after readmission, omitting necessary revisions for anticoagulant and antianxiety medications. The resident, initially admitted and later readmitted, had physician orders for Apixaban and Clonazepam, but the new care plan did not reflect these medications. The DON confirmed the oversight during a surveyor's record review.
The facility failed to administer and document care as ordered for two residents. A resident with constipation did not receive prescribed as-needed medications despite not having bowel movements for several days, and another resident with a urinary catheter had no documentation of urinary output as required. The DON confirmed these deficiencies.
A resident in the facility had been missing a lens from their glasses for months and had not seen an ophthalmologist since admission, despite informing staff and having a consult ordered. The Director of Nursing confirmed the lack of follow-up on the resident's vision needs.
A facility failed to provide adequate colostomy care for a resident, as there was no physician order for the care of the colostomy. The resident was observed with a colostomy bag, but a review of medical records confirmed the absence of a physician order. The RN Unit Manager and the DON acknowledged the oversight, which was only addressed after surveyor intervention.
A facility failed to maintain 'oxygen in use - no smoking' signage for a resident requiring continuous oxygen therapy. Despite a physician's order and documented use of oxygen every shift, the necessary safety signage was not observed on multiple occasions. The RN Unit Manager acknowledged the requirement for signage and suggested it may have fallen off, indicating a lapse in maintaining safety protocols.
The facility failed to ensure residents' medication regimens were free from unnecessary drugs. One resident received duplicate sodium chloride doses due to overlapping orders, while another was given levofloxacin despite hospital instructions to stop the medication. These issues highlight a lack of proper medication management and order updates.
A facility failed to coordinate routine dental services for a resident, whose teeth were observed to be black by their representative. A dental consult was ordered, and the resident was last seen by the Dental Group, which recommended biannual cleanings. However, the DON stated that specialty care groups are responsible for scheduling, leading to a lack of coordination in ensuring timely dental care.
A facility failed to maintain accurate records for a resident transferred to the hospital. The transfer form lacked the name of the notified representative, although the date and time were recorded. An LPN confirmed notifying the representative but did not lock the note until later, resulting in incomplete records. The DON acknowledged the issue of missing information due to unlocked notes.
A facility failed to follow proper infection control practices by using a plastic bag to line a commode for a resident, even after the resident's stomach infection was cleared. Staff were unsure of the correct disposal method, and the DON clarified that waste should be disposed of in biohazard bags.
A facility failed to notify and obtain consent from a resident's representative for immunizations. The resident, with a BIMS score indicating severe cognitive impairment, had verbal declinations for vaccinations signed by the Infection Preventionist without consulting the representative. The oversight was acknowledged by the facility's staff, highlighting a lapse in following proper procedures for residents unable to make their own medical decisions.
Inaccurate MDS Coding for Falls and Insulin Use
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents. For one resident admitted from the hospital with a closed left scapular fracture after a fall at home, the Admission/Medicare 5-Day MDS dated 2/13/2026 was coded in Section J1800/1900 to show two falls since admission to the facility, one with no injury and one with a major injury. Record review showed the resident had not experienced any falls in the facility since admission on 2/9/2026, and the DON confirmed there were no in-facility falls for this resident. The inaccurate coding therefore reflected falls that did not occur during the resident’s stay. Another resident’s record showed two documented in-facility falls, one on 2/11/2026 with no injury and one on 2/16/2026 with injury (except major). These two falls were correctly captured on the 2/20/2026 End of PPS Part A Stay MDS in Section J1800/1900 as one fall with no injury and one fall with injury (except major). However, the subsequent Discharge Return Anticipated MDS dated 2/28/2026 was also coded to show one fall with no injury and one fall with injury (except major), despite there being no documentation of any additional falls after those already recorded on the 2/20/2026 assessment. The DON confirmed that the resident had only the two documented falls and no further incidents. For a third resident, the Quarterly MDS assessment dated 2/26/2026 contained inaccurate medication coding. In Section N0350 (Insulin), the assessment indicated that insulin injections were received on seven days during the look-back period. Review of the electronic medical record revealed there were no orders for insulin for this resident. During interview, the MDS Coordinator explained that Ozempic had been coded as an insulin, and acknowledged this as an error. These findings demonstrate that the facility did not consistently perform accurate MDS assessments for falls and insulin use as required by the assessment tool.
Failure to Notify Resident/Responsible Party of Room Change
Penalty
Summary
Facility staff interviews and surveyor record review identified a failure to provide required notification of a room change to a resident and/or the resident’s responsible party. Record review of a closed medical record for Resident #107, conducted on 3/13/2026, showed that the resident was transferred from room [ROOM NUMBER]-A on station 2 to room [ROOM NUMBER]-B on station 1 on 2/4/2026. The medical record contained no documentation indicating that the resident or the responsible party had been notified of this room change. During an interview on 3/13/2026 at 8:38 AM, the DON was informed by the surveyor that there was no documentation of notification for the room transfer. The DON stated she would look for the room change notification. In a follow-up interview at 9:20 AM the same day, the DON reported she was unable to locate any documentation of notification for the room change, while acknowledging that the facility’s expectation was to notify the resident and/or responsible party of room changes and to document such notifications in the medical record. By the time of survey exit, no information or documentation of notification for Resident #107’s room change had been provided.
Facility Maintenance and Resident Property Security Deficiencies
Penalty
Summary
The facility staff failed to maintain a safe and homelike environment, as evidenced by several maintenance issues observed during an environmental tour. In one room, the baseboard adjacent to a resident's closet was damaged with jagged edges, and the shower room on the 200 unit had ceiling tiles with brown stains and exposed copper pipes protruding from the wall. Additional observations included missing floor tiles, unsecured baseboards, and warped sink countertops in various resident rooms. The Nursing Home Administrator acknowledged awareness of these issues and mentioned a plan for repairs, but no immediate corrective actions were noted. Furthermore, the facility failed to protect a resident's personal property from wandering residents. A resident expressed distress over a broken cell phone charger and missing items, including a notebook, due to other residents entering their room. Despite being aware of the wandering residents, the Director of Nursing and Clinical Director were not informed about the specific incident involving the cell phone charger. The resident, who was alert and oriented, continued to feel unsafe and concerned about the security of their belongings.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility staff failed to protect residents from abuse, as evidenced by two separate incidents involving resident-to-resident interactions. In the first incident, a staff member witnessed a resident undressing and inappropriately touching another resident at their bedside. The staff member immediately intervened by calling for assistance and removing the offending resident from the room. The local police were notified, and the resident was subsequently arrested and did not return to the facility. This incident was identified as a non-compliance sexual abuse concern by the surveyor. In the second incident, facility staff responded to a commotion in a resident's room and found two residents with their arms intertwined. One resident pushed the other, causing them to fall to the floor. Following this incident, the resident who fell was placed on one-to-one observation. The Executive Director acknowledged the surveyor's concern regarding resident-to-resident abuse. Both incidents highlight the facility's failure to maintain a safe environment and protect residents from abuse by other residents.
Failure to Provide Adequate Personal Hygiene Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for two residents who were dependent on staff for assistance with activities of daily living (ADLs). Resident #449, who had an ileostomy, expressed concerns about the care of their ostomy. The resident's care plan, initiated on 11/18/24, indicated a need for assistance with ostomy care. However, the Minimum Data Set (MDS) assessment completed on 10/20/24 documented that the resident was dependent on staff for managing the ostomy. Despite this, the Treatment Administration Record (TAR) for December did not document any ostomy care until 12/5/24, when orders were finally entered. The Director of Nursing confirmed that the ostomy care orders were not entered at the time of admission, and there was no documentation to show that the resident received the necessary care according to their care plan. Resident #68's representative reported that during a visit on 10/28/24, the resident's toenails were unkempt and excessively long. The facility's investigation confirmed that the toenails were addressed after the complaint, and podiatry was consulted. The resident's last podiatry visit was on 4/24/24, where the podiatrist noted that non-professional treatment was hazardous. The MDS assessment conducted on 10/31/24 indicated that the resident was dependent on staff for personal hygiene and required assistance from two or more helpers for putting on and taking off footwear. This lack of timely and adequate care for personal hygiene needs highlights the facility's failure to provide necessary services for dependent residents.
Failure to Provide Adequate Supervision During Incontinent Care
Penalty
Summary
The facility failed to protect a resident from preventable accidents, as evidenced by an incident involving a fall. On December 10, 2023, a resident fell off the bed while a Geriatric Nursing Assistant (GNA) was providing incontinent care. The resident was subsequently evaluated at a hospital, where no injuries or fractures were identified. The resident's Multiple Data Set (MDS) assessment, conducted on September 29, 2023, indicated that the resident was dependent and required two or more helpers for toileting hygiene. However, at the time of the incident, only one GNA was assisting the resident, contrary to the care plan initiated on December 5, 2019, which specified that repositioning should be done with two people, a lifter, or a slider. The Director of Nursing confirmed that only one GNA was involved in the incident.
Inadequate Pain Management for Resident with Baclofen Pump
Penalty
Summary
The facility staff failed to provide appropriate pain management for a resident with an intrathecal baclofen pump, which is used to treat severe spasticity. The resident, who had a history of a traumatic brain injury, quadriplegia, and severe spasticity, was observed with rigid extremities and mild contractions, indicating potential issues with the pump's function. The resident's medical records showed a lack of documentation regarding the assessment and monitoring of the pump's effectiveness and potential complications, such as catheter disconnections or pump dysfunction. Interviews with facility staff revealed that the nursing staff had not received training on the care and monitoring of intrathecal baclofen pumps, leading to a lack of standard care practices. The facility's administration acknowledged the deficiency, noting that they only had information on the next refill date for the pump but lacked details on the combined dosage orders, current pump dosage settings, and battery status. This oversight resulted in inadequate monitoring and management of the resident's pain and spasticity, as well as a failure to ensure the pump's proper functioning.
Failure to Accurately Document and Review Resident's Care Plan
Penalty
Summary
The facility failed to ensure that the medical provider thoroughly reviewed and accurately documented a resident's updated plan of care after a visit. This deficiency was identified for one resident who had been admitted to the facility and subsequently experienced multiple hospitalizations due to medical complications, including mental status changes and a dislodged PEG tube. Upon returning to the facility, the resident's medication orders were not accurately updated to reflect the change from oral administration to PEG tube administration, leading to discrepancies in the medication administration records. The surveyor found that both the Nurse Practitioner and Physician documented that the resident was receiving medications via the oral route, even after the orders had been changed to PEG tube administration. Additionally, the Director of Nursing was unable to confirm the correct route of medication administration, and the Medical Director acknowledged that the oversight regarding the lisinopril administration route may have been an error. This lack of accurate documentation and review of the resident's care plan by the medical providers contributed to the deficiency identified during the survey.
Facility Lacks Effective Pest Control Program for Gnats
Penalty
Summary
The facility failed to ensure an effective pest control program, as evidenced by the presence of flying gnats throughout the building. Surveyors observed gnats in various locations, including a toilet room, near the entrance of a room, and around the nurses' station. The Food Service Director confirmed the presence of gnats in the kitchen, particularly by the floor drains and juice machine, and mentioned that the maintenance department was contacted to address the issue. However, a review of maintenance records for the affected room did not reveal any pest control visits or interventions for gnats. Further investigation into the facility's Pest Control Binder showed numerous reports of gnats in resident care areas from 2017 through 2022, but no documented resolutions to address these reports. The Maintenance Director acknowledged the reports of gnats and stated that a device was used to treat the areas and the pest control company was called in. Despite this, there was no documentation provided to surveyors to demonstrate how the issue was treated or prevented. The Director of Nursing and the Maintenance Director were informed of the survey team's concerns about the lack of documentation and the multiple observations of gnats in the facility.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide a resident with an environment that promotes a dignified existence, as observed in the case of Resident #349. On December 2, 2024, a surveyor observed a clear plastic bag lining the commode in the resident's room, containing a yellow-colored liquid and a piece of toilet paper. When questioned, RN #3 was unsure why the bag was there, suggesting that the resident does things their way. Further inquiry with RN #7 revealed that the bags were initially used to dispose of waste when the resident had a stomach infection, and the practice continued even after the resident was cleared from the infection.
Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call bells were within reach of a resident, as observed during a recertification survey. On multiple occasions, surveyors found the call bell of Resident #79 on the floor, out of reach. On 12/2/2024, the call bell was observed on the floor next to the resident's bed. This issue persisted, as on 12/4/2024, the call bell was again found on the floor. Geriatric Nursing Assistant #11 confirmed the call bell's location and placed it back within reach. On 12/5/2024, the call bell was once more found on the floor behind the bed. Licensed Practical Nurse #15 acknowledged the expectation that call bells should be within reach and noted the absence of a clip for the call bell. The Registered Nurse Unit Manager confirmed the facility's policy that call bells should always be accessible to residents. The Director of Nursing acknowledged the concerns raised by the surveyors.
Failure to Document Advance Directives and Ensure MOLST Accuracy
Penalty
Summary
The facility staff failed to document whether Resident #32 had an advance directive or wished to formulate one upon admission. The surveyor found no Social History Assessment - Maryland v7 form in Resident #32's medical record, which is where documentation on advance directives was typically found for other residents. During an interview, the Director of Nursing (DON) acknowledged the absence of this documentation and stated that Resident #32 did not have advance directives because the resident was unable to make decisions at the time of admission. No additional information was provided by the DON. For Resident #23, the facility staff did not ensure the accuracy of the Medical Orders for Life-Sustaining Treatment (MOLST) form. The decision-making section of the MOLST form was left blank, despite the presence of an advance directive on file since 2021. The Director of Nursing and the Administrator confirmed that Doctor staff #24 had completed the MOLST form but failed to check the correct option box, which was an omission. The advance directive had been directing the resident's care decisions since 2021, and the surveyor noted this omission as a concern.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents and/or their representatives upon transfer to an acute care facility. This deficiency was identified for two residents during a survey. In the first case, a resident was transferred to the hospital, and a bed hold was initiated by a unit manager without documented communication with the resident or their representative. The Admissions Director stated that she had reached out to the resident's representative and mailed the policy, but there was no confirmation of receipt or agreement. The discrepancy arose because the nursing staff on the weekend may have incorrectly sent the bed hold document. In the second case, another resident was transferred to the hospital twice, but the representative was only notified of the bed hold policy for the first transfer. The Admissions Director admitted that the policy was not communicated for the second transfer because the resident was only in the emergency room, despite staying overnight. The director acknowledged that she has since been notifying residents and their representatives of the bed hold policy for all hospital transfers, regardless of the duration or nature of the stay.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to accurately document resident assessments on the Minimum Data Set (MDS) for two residents, leading to deficiencies in the accuracy of their medical records. For one resident, who was observed with a colostomy bag, the MDS was inaccurately coded in the Discharge and Medicare/5-day assessments. The coding errors included marking the resident as having no appliances and being always incontinent, despite the presence of a colostomy. The MDS Director acknowledged these inaccuracies during an interview with the surveyor. Another resident's quarterly MDS assessment inaccurately documented the absence of hospice services, despite the resident being on hospice since April 2023. This error was identified during a review of the resident's care plan and MDS assessment. The MDS Director confirmed the mistake and indicated that it was an error in coding. The Executive Director also acknowledged the concern regarding the inaccurate MDS coding.
Failure to Update PASARR After New Diagnosis
Penalty
Summary
The facility failed to initiate a new pre-admission screening and resident review (PASARR) Level I screen after a resident was diagnosed with bipolar disorder while admitted to the nursing facility. Initially, the resident was admitted from an acute care hospital with a PASARR Level I screening completed, which did not identify the need for a Level II evaluation. However, during the resident's stay, a diagnosis of bipolar disorder was added, which should have triggered a new PASARR Level I screening to determine if a Level II evaluation was necessary. The deficiency was identified during a recertification survey, where it was noted that the resident's medical record showed the diagnosis of bipolar disorder was added after admission. The facility's Admissions Director acknowledged that a new PASARR Level I should have been conducted following the updated diagnosis. The Executive Director also recognized the issue, indicating that there is now a process in place to update PASARRs when new mental disorder or intellectual disorder diagnoses are identified during a resident's stay.
Failure to Include Dietary Needs in Baseline Care Plan
Penalty
Summary
The facility failed to include all necessary initial healthcare information in the baseline care plan for a resident within 48 hours of admission. Specifically, the baseline care plan for a resident with a medical history of congestive heart failure, atrial fibrillation, malaise, digestive system disease, and dementia did not address the resident's dietary and nutritional needs. This omission was identified during a review of the resident's medical records and care plans, which showed that while other care plans were initiated shortly after admission, the dietary and nutritional care plan was not included in the baseline care plan. Interviews with facility staff, including the Director of Nursing, MDS staff, and the Nursing Home Administrator, revealed that the baseline care plan is typically initiated by the nurse manager and supplemented by MDS staff based on further assessments. The facility's policy requires that the baseline care plan, also known as the 48-hour care plan, address physician and dietary orders. However, in this case, the baseline care plan did not include a care plan for diet/nutrition, despite the resident's comprehensive care plan indicating a need for a special diet with supervisory intervention.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident #94, admitted in October 2024, had a history of urinary retention and was observed with an indwelling urinary device, yet lacked a corresponding care plan. Additionally, the care plan for Activities of Daily Living (ADLs) was improperly developed, indicating multiple dependency levels instead of a single level of support. Interviews with the Director of Nursing (DON) and MDS staff confirmed these oversights, acknowledging errors in the support assessment and the absence of a care plan for the urinary device. Resident #77 was found to have a missing lens in their glasses, which had been reported to staff months prior, yet no action was taken to address this issue or schedule an ophthalmologist appointment. The resident's care plan lacked any focus on vision or accessibility to glasses. Similarly, Resident #42, who was admitted with a colostomy, did not have a care plan addressing colostomy care and services. Interviews with the DON and RN Unit Manager confirmed the absence of a care plan for the colostomy, despite the resident's needs.
Failure to Update Care Plan Post-Readmission
Penalty
Summary
The facility failed to update and revise the care plan for a resident following their readmission. The resident, who was initially admitted on October 8, 2024, and discharged to the hospital on October 27, 2024, was readmitted on November 3, 2024. Despite having physician orders for Apixaban for DVT and Clonazepam for anxiety, the care plan was not revised to reflect the usage and monitoring of these medications after the resident's readmission. The Director of Nursing confirmed that the resident had two separate care plans: one that was closed upon discharge to the hospital and another initiated upon readmission. However, the new care plan did not include updates or revisions for the anticoagulant and antianxiety medications, which were present in the original care plan. This oversight was identified during a record review conducted by the surveyor on December 5, 2024.
Failure to Administer and Document Care as Ordered
Penalty
Summary
The facility failed to provide treatments according to the care plan for two residents. Resident #71, who had a care plan for constipation due to decreased mobility, did not receive the prescribed as-needed medications for constipation despite not having a bowel movement for several days. The resident's care plan included the administration of Senna, Miralax, and as-needed Dulcolax suppository and fleet enema. However, the Medication Administration Record showed that these as-needed medications were not administered, and there was no documentation of bowel movements for several days. The Director of Nursing confirmed the lack of documentation and the failure to administer the medications as ordered. Resident #94, who had a history of urinary retention, was observed with a urinary bag but lacked documentation of urinary output as required by the physician's order. The order specified that foley catheter care and documentation of output should occur every shift. However, the Treatment Administration Record and point of care documentation showed no recorded urinary output. The Director of Nursing acknowledged the failure to document the urinary output according to the physician's order.
Failure to Coordinate Vision Services for a Resident
Penalty
Summary
The facility failed to coordinate vision services for a resident, as evidenced by the case of Resident #77. During an observation and interview, it was noted that the resident had been missing a lens from their glasses for months and had informed the staff, but no follow-up occurred. The resident also reported not having seen an ophthalmologist since their admission to the facility. A review of the resident's records showed that a consult for various services, including optometry and ophthalmology, was ordered months prior, but the resident had not been seen by an ophthalmologist. An interview with the Director of Nursing confirmed that the resident had not received ophthalmology services since admission, and the missing lens issue had not been addressed.
Lack of Physician Order for Colostomy Care
Penalty
Summary
The facility failed to provide adequate care and services for a resident requiring colostomy care. During an observation, the surveyor noted that the resident had a colostomy bag on the abdomen. However, upon reviewing the resident's medical records, it was discovered that there was no physician order for the care of the colostomy. This lack of documentation was confirmed during an interview with the RN Unit Manager, who acknowledged that the resident was admitted with a colostomy but did not have a corresponding physician order for its care. Further investigation revealed that the Director of Nursing, along with the Nursing Home Administrator, was informed of the deficiency. The Director of Nursing confirmed the absence of a physician order for colostomy care for the resident. This oversight was only addressed after the surveyor's intervention, highlighting a lapse in the facility's protocol for managing residents with specific medical needs such as colostomy care.
Failure to Maintain Oxygen Safety Signage
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident who required continuous oxygen therapy. During a tour of Unit 200, the surveyor observed that the resident was using oxygen but there was no 'oxygen in use - no smoking' signage posted on the resident's room door. This observation was made on multiple occasions, including on 12/2/2024, 12/4/2024, and 12/6/2024. The absence of the required signage was confirmed through interviews with the RN Unit Manager, who acknowledged that the signage should be posted on the resident's room door or doorframe. The resident's medical record review revealed a physician's order for continuous oxygen and a care plan intervention for oxygen therapy, which had been documented as being used every shift daily since 11/1/2024. Despite this, the necessary safety signage was not maintained, indicating a lapse in the facility's adherence to safety protocols for residents receiving oxygen therapy. The RN Unit Manager suggested that the signage might have fallen off, but this does not mitigate the facility's responsibility to ensure proper safety measures are consistently in place.
Medication Regimen Deficiencies
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs, as evidenced by the cases of two residents. For the first resident, there was a duplication in the administration of sodium chloride. The resident was initially prescribed sodium chloride 1 gram to be given three times a day, and on a subsequent date, a new order for sodium chloride 2 grams daily was written. Both orders were administered on the same day before the original order was discontinued, resulting in an unnecessary duplication of medication. The resident's primary care physician confirmed that such duplication is not standard practice and indicated that the nurse practitioner involved would be educated on avoiding duplicate orders. In the second case, a resident returned to the facility with a PEG tube after hospitalization. Upon return, levofloxacin was ordered and administered via the oral route, despite the hospital discharge summary indicating that the medication should be stopped. The order was later changed to the PEG tube route and then discontinued shortly after. This indicates a failure to update the resident's medication orders according to the current plan of care, as noted by the surveyor during an interview with the Director of Nursing.
Failure to Coordinate Routine Dental Services
Penalty
Summary
The facility failed to coordinate routine dental services for a resident, as evidenced by the case of Resident #68. The resident's representative observed the resident's teeth were black during a visit on 10/28/24, raising concerns about the resident's dental care. A complaint was filed regarding the resident's dental care and appointments. A review of the resident's orders showed that a dental consult was ordered on 8/28/23, and the resident was last seen by the Dental Group on 10/30/23. The dental note from that visit recommended the resident be seen every six months for cleaning, with the next appointment scheduled for 10/30/24. However, the Director of Nursing stated that specialty care groups are responsible for following up with recommendations and scheduling appointments, indicating a lack of coordination in ensuring the resident received timely dental care.
Incomplete Resident Record Documentation
Penalty
Summary
The facility failed to maintain accurate resident records in accordance with professional standards, as evidenced by the case of Resident #54. On December 1, 2024, Resident #54 was transferred to the hospital, and the transfer form included a section for Resident Representative Notification. Although the date and time of notification were recorded, the name of the representative was left blank. During an interview, LPN Staff #27 confirmed that she had notified the resident's representative but did not lock the note until December 3, 2024, which resulted in incomplete information in the medical record. The Director of Nursing acknowledged the concern that unlocked notes lead to missing information and incomplete records.
Improper Waste Disposal Practices
Penalty
Summary
The facility failed to adhere to proper infection control practices in handling a resident's waste. During an observation, a clear plastic bag was found lining the commode in a resident's room, containing a yellow-colored liquid and a piece of toilet paper. A registered nurse was unsure why the bag was used, attributing it to the resident's personal habits. Another nurse explained that the bags were initially used when the resident had a stomach infection, but continued to be used even after the infection was cleared. The nurse was unable to explain how the waste was disposed of and sought clarification from the Director of Nursing, who stated that waste should be disposed of in biohazard bags and that all staff should be aware of this procedure.
Failure to Obtain Immunization Consent from Resident's Representative
Penalty
Summary
The facility failed to notify and obtain consent from a resident's representative for immunizations, as identified during a recertification survey. Specifically, Resident #92, who had a BIMS score of 00 indicating severe cognitive impairment, had verbal declinations for influenza and pneumococcal vaccinations signed by the facility's Infection Preventionist (IP) without consulting the resident's representative. The resident's medical records indicated a designated representative, but there was no documentation that this representative was contacted regarding the resident's verbal declination of immunizations. During an interview, the facility's IP confirmed that for residents lacking capacity to make their own medical decisions, the representative should be consulted, and acknowledged the absence of such documentation for Resident #92. The Executive Director also acknowledged the surveyors' concerns about the lack of contact with the resident's representative. This oversight was later rectified when the representative was contacted and consent was obtained, but the initial failure to follow proper procedures led to the deficiency.
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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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