The Village At Rockville
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockville, Maryland.
- Location
- 9701 Veirs Drive, Rockville, Maryland 20850
- CMS Provider Number
- 215125
- Inspections on file
- 14
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Village At Rockville during CMS and state inspections, most recent first.
The facility failed to thoroughly investigate two abuse allegations involving injuries of unknown origin by not consistently conducting and documenting resident interviews and assessments. In both cases, initial incident reports listed actions such as initiating investigations, notifying physicians and families, and performing limited clinical assessments, but did not include resident interviews or broader assessments as protective steps. Investigation files contained multiple staff interviews but lacked documented interviews with other residents or clear assessment data tied to the incidents. The NHA acknowledged that interviewing both staff and residents is best practice and believed social services had completed resident interviews, yet could not produce documentation. The DON reported that non-interviewable residents were not interviewed and that monitoring occurred through observation and family contact, but was unable to provide complete assessment records related to the incidents.
A resident with HTN had orders for Amlodipine and Metoprolol with parameters to hold doses if SBP was below 110 and, for Metoprolol, if HR was below 60. Despite this, Metoprolol was administered when the resident’s SBP was 101, and multiple BP readings below the ordered parameter were documented without evidence that the physician was notified or that medications were held as ordered. Separately, maintenance hot water logs showed the same temperature values carried across all resident rooms using lines and arrows instead of recording actual temperatures for each room, and the Maintenance Director acknowledged the logs were not completed accurately.
A facility investigation into an alleged abuse/neglect incident found that a GNA provided care in a rushed and disruptive manner that did not meet acceptable standards of quality. A PDA and a family member reported that the GNA moved quickly, slammed and rapidly opened/closed cabinet doors in a resident’s room, and left a dirty blanket on the bed. The resident also reported that the staff member moved too quickly while providing care. Although abuse was not substantiated, these observations showed that the resident did not receive compassionate, quality care consistent with their preferences and goals.
A resident's MOLST form instructed to attempt CPR, but due to a miscommunication, staff did not initiate CPR when the resident was found unresponsive. The RN relied on a shift report form indicating a DNR status, which was incorrect. The RN supervisor also failed to initiate CPR after verifying the correct code status in the resident's chart. The attending provider later advised against CPR due to the resident's condition.
The facility failed to provide mandatory communication training for direct care staff, including GNAs, LPNs, and an RN. A review of training records for eight randomly selected staff members revealed no documentation of completed communication training. This deficiency was identified during an extended survey following an Immediate Jeopardy situation. The Nursing Home Administrator was informed, but no further evidence was provided.
The facility failed to report allegations of abuse within the required two-hour timeframe for multiple incidents. In one case, a resident alleged being compromised at night, but the report was delayed by over 24 hours. Another incident involved a resident claiming a staff member put their head in a toilet, with a similar reporting delay. Additionally, a resident requiring assistance was refused help by a GNA, and the incident was not reported until the following day. The facility did not initially identify these situations as potential abuse, contributing to the deficiency.
The facility failed to obtain informed consent for bed rail use for two residents. Observations revealed that both residents had bed rails in use, but their medical records lacked consent documentation. The DON stated that consent was part of the assessment process, but no evidence of consent was found. The NHA confirmed the absence of consent for both residents.
The facility failed to ensure pharmacists' recommendations on medication irregularities were communicated to physicians for three residents. Reports were not documented in medical records, and there was no evidence that physicians reviewed or acted on the recommendations, indicating a breakdown in communication and documentation processes.
A resident's call bell went unanswered for over 42 minutes on multiple occasions, despite staff expectations to respond within 8 minutes. Interviews with a GNA and LPN revealed the facility lacked a formal call bell policy, and the DON and NHA acknowledged the deficiency.
A resident who required assistance with transfers was denied help by a GNA after lunch, despite expressing discomfort and a desire to return to their room. The GNA refused to assist and dismissed the resident's requests, leading the resident to attempt to wheel themselves back to their room. Other staff eventually assisted the resident, and the incident was reported the next day. The GNA's actions were confirmed, resulting in her termination.
A facility failed to thoroughly investigate an abuse allegation involving a resident. A family member reported the alleged abuse to a supervisor, but the investigation lacked interviews with the family member, the resident, and the supervisor. The DON acknowledged the missing interviews during a discussion.
A facility failed to notify a primary care provider about a lab result for a resident with a urinary tract infection. A urine specimen was spilled in transit, and although a nurse was informed, there was no documentation of communication with the provider. The nurse's responsibility includes reviewing lab results, notifying the provider, and documenting the communication, which was not done in this case.
The facility failed to maintain a safe environment, with a broken lock on a housekeeping closet and unrepaired drywall in resident rooms. A housekeeping closet was found unlocked, and a hole in a bathroom wall was stuffed with toilet paper. The Maintenance Director was unaware of these issues, and no work orders were found for the damaged drywall.
The facility failed to include a resident's care plan in the transfer documentation during hospitalization. Interviews with LPNs revealed that while a transfer checklist was used, it did not include the care plan. The DON confirmed that care plans should be sent with residents, but this was not being done, resulting in a deficiency.
The facility failed to provide written transfer notices to two residents and their representatives during hospitalizations. For one resident, no written notice was found for two hospitalizations, and verbal notifications were inconsistently documented. For another resident, despite documentation of a hospital transfer due to respiratory distress, there was no evidence of a written notice being provided. The NHA and DON confirmed these deficiencies.
The facility failed to properly orient and document the transfer of two residents to the hospital. One resident's medical records lacked evidence of preparation for hospitalizations, while another resident was transferred for respiratory distress without documentation of being informed about the transfer. The DON confirmed these deficiencies.
The facility failed to provide written notification of its bed-hold policy to residents and their representatives upon transfer to a hospital. For two residents, there was no documentation of written notice, only verbal communication was noted. The facility was unable to produce evidence of written notifications, indicating a systemic issue in compliance with notification requirements.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked measurable goals and non-pharmaceutical interventions for managing psychosis, despite receiving psychotropic medications. Another resident's care plan did not indicate the presence of a hearing aid, even though it was noted in the MDS assessment. The DON confirmed these deficiencies.
A private duty aide, not licensed to feed residents, was observed feeding a resident who required assistance in the dining room. Despite the presence of other staff, no intervention occurred. The aide was hired for another resident and fed the resident multiple times without proper authorization.
A facility failed to provide clear guidelines for administering as-needed medications for constipation to a resident. The resident's MAR included three medications for constipation, with no instructions on which to administer first. Two orders were for the same medication, leading to potential confusion. The issue was acknowledged by the DON.
A facility failed to adequately monitor a resident's behavior and side effects related to psychotropic medication use. The resident, with moderate cognitive impairment and multiple medical diagnoses, was prescribed Duloxetine, Quetiapine, and Lorazepam. Despite orders to monitor behavior, the facility did not document specific behaviors or non-pharmacological approaches, nor did they monitor the resident for behaviors related to the prescribed antipsychotic.
The facility failed to store food items properly, leading to a risk of cross-contamination. A surveyor found a sausage without a label or date in the walk-in freezer, which was removed by the Dining Services Supervisor. Additionally, in the second-floor kitchen, a surveyor observed uncovered and unlabeled salsa and sour cream with a scoop inside. A dining server identified and removed these items after being shown by the surveyor. The Dining Director acknowledged the improper storage.
The facility failed to maintain accurate medical records by not voiding outdated MOLST forms when new ones were created, resulting in multiple active forms with conflicting orders for three residents. This issue was identified during a survey, revealing discrepancies between the electronic medical records and hard charts.
A facility failed to maintain proper infection control practices when a resident's Foley catheter bag was observed lying flat on the floor. A nurse confirmed the observation and acknowledged that the catheter bag should not be in contact with the floor. The nurse adjusted the bed to prevent the catheter from touching the floor, suggesting the bed had been lowered, causing the issue.
The facility failed to educate two residents or their representatives on the risks and benefits of pneumonia vaccinations, as evidenced by the lack of documentation for informed consent. The Infection Preventionist nurse confirmed this deficiency.
Failure to Conduct and Document Resident Interviews and Assessments in Abuse Investigations
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate two separate allegations of abuse related to injuries of unknown origin for two residents. For the first incident involving Resident #74, the initial incident report listed actions such as initiating an investigation and notifying the family, physician, medical director, and ombudsman, but did not include resident interviews or resident assessments as immediate protective steps. Review of the facility’s abuse investigation file showed eight staff interviews but no resident interviews or assessments. The follow-up investigation report also confirmed that only staff were interviewed. During interviews, the Nursing Home Administrator (NHA) acknowledged that including both staff and resident interviews is best practice and stated she believed the social worker had completed resident interviews. The DON reported that they do not interview residents who are considered non-interviewable, instead looking for signs or symptoms of abuse and contacting families, and indicated that any screening would be documented through skin assessments. However, the DON could only produce a limited number of skin assessments for some non-interviewable residents and these were not clearly tied to the abuse investigation. For the second incident involving Resident #140, the initial incident report for an injury of unknown origin documented steps such as initiating an investigation, completing a head-to-toe assessment, medicating for pain, notifying the physician, responsible party, and medical director, ordering an x-ray, and updating the care plan, but again did not list resident interviews or broader resident assessments as part of the immediate protective actions. The abuse investigation file contained nine staff interviews but no documentation of resident interviews or assessments. The follow-up investigation report indicated that only staff and the involved resident were interviewed. The NHA confirmed the investigation file was complete, reiterated that she believed the social worker had conducted resident interviews, and produced an email stating that three residents on the same hallway had been interviewed, but no written interview documentation could be provided. The DON stated they do not interview non-interviewable residents, instead monitoring for signs or symptoms and contacting families, and was unable to provide any documentation of completed resident assessments related to this incident, demonstrating that resident interviews and assessments were not consistently conducted or documented as part of the abuse investigations.
Failure to Follow Antihypertensive Parameters and Accurately Document Hot Water Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice for a resident receiving antihypertensive medications. Review of the resident’s MAR showed orders for Amlodipine 10 mg at bedtime and Metoprolol Succinate ER 50 mg daily for HTN, with instructions to hold both medications if the systolic blood pressure (SBP) was less than 110, and to hold Metoprolol if the heart rate was less than 60. On one morning, RN #28 administered Metoprolol despite the resident’s SBP being 101, which was below the ordered hold parameter. Review of the resident’s blood pressure readings showed multiple SBP values below 110 on several dates, including 103/57, 101/58, 102/57, 94/51, and 98/56. The medical record did not contain documentation that the physician was notified when the resident’s SBP was less than 110 or that the medication was held as ordered. A second deficiency was identified related to maintenance documentation of hot water temperatures. Review of the facility’s hot water logs showed that on multiple dates, a single temperature (ranging from 119°F to 121°F) was recorded with a line and downward arrow drawn through each box for every resident room, instead of documenting the actual temperature for each room. During interview, the Maintenance Director acknowledged that the hot water logs were not completed accurately or completely, confirming that the recorded temperatures did not reflect individual room measurements as required.
Failure to Provide Compassionate, Quality Care During Personal Care Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received care that met acceptable standards of quality, in accordance with orders, preferences, and goals. During review of a facility-reported incident involving allegations of abuse and neglect by a GNA toward one resident, multiple interviews documented concerns about the manner in which care was delivered. A Patient Decision Aide who worked with the resident on two consecutive days reported observing the GNA slamming cabinet doors in the resident’s room, moving quickly while opening and closing doors, and leaving a dirty blanket on the resident’s bed. These observations were recorded as part of the facility’s internal investigation. A family member of the same resident reported observing the GNA rapidly opening and closing cabinet doors in the resident’s room and stated that the GNA did not appear compassionate while providing care. In a separate interview, the resident reported that the GNA “moves too quickly” when providing care. Although the facility’s investigation did not substantiate abuse, the collected interviews consistently described rushed, abrupt care, environmental disruption (slamming and rapidly opening/closing cabinet doors), and failure to maintain a clean bed surface, which together demonstrated that the resident did not receive care that met acceptable standards of quality.
Failure to Initiate CPR Due to Miscommunication of Code Status
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) to an unresponsive resident whose Maryland Orders for Life Sustaining Treatment (MOLST) instructed to attempt CPR in the event of cardiac and/or pulmonary arrest. The incident involved a resident who was found unresponsive by a geriatric nurse aide (GNA) and subsequently assessed by a registered nurse (RN), who noted the resident had cold clammy skin, no rise and fall of the chest wall, and dilated pupils. Despite these observations, the RN did not initiate CPR, as the resident's MOLST form instructed. The failure to initiate CPR was attributed to a miscommunication regarding the resident's code status. The RN relied on a change of shift report form that incorrectly indicated the resident had a Do Not Resuscitate (DNR) order. This misinformation was compounded when the RN supervisor also failed to initiate CPR after checking the resident's physical chart, which correctly indicated the need to attempt CPR. The attending provider was contacted and advised against initiating CPR due to the resident's condition at that time.
Removal Plan
- The staffing agency was notified of the occurrence, and staff #8 was placed on the Do Not Return list for the facility.
- A document review was conducted on all units to ensure code status information was only available on the MOLST form in the residents' physical charts.
- Nursing staff were re-educated on MOLST and the CPR process by the RN unit managers.
- Policy on MOLST and CPR and education were activated in the facility's training software program for nursing staff review and acknowledgment.
- The 3 Unit Managers (Care Coaches) also provided in-person training to all nursing staff.
- The Medical Director provided education to all attending physicians (including Resident #137's attending provider).
- The facility audited and reviewed all residents' MOLST forms and orders.
Lack of Mandatory Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff received mandatory communication training, as evidenced by a review of training records for eight staff members, including Geriatric Nursing Assistants, Licensed Practical Nurses, and a Registered Nurse. During the extended survey portion of the recertification survey, it was discovered that none of the eight randomly selected staff members had documentation of completed communication training. This deficiency was identified following an Immediate Jeopardy situation during the standard survey, prompting a more in-depth review of staff training records. The Nursing Home Administrator was informed of the lack of evidence for mandatory communication training, but no further evidence was provided to address this deficiency.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe for four facility-reported incidents. In one case, a responsible representative informed the facility of an allegation involving female residents being compromised at night, but the report to the Office of Healthcare Quality was delayed by over 24 hours. Another incident involved a resident alleging that a staff member put their head in a toilet, but the report was not made until the following morning. Similar delays were noted in two other incidents, where reports were made several hours after the allegations were initially reported to staff. Additionally, the facility did not identify and report potential abuse involving a resident who required assistance with transfers. The resident requested help from a geriatric nursing assistant (GNA) to return to bed after lunch, but the GNA refused, stating she would assist after dinner. The resident, experiencing discomfort, attempted to return to their room independently until another staff member intervened. The incident was not reported to the state survey agency until the following day, and the Director of Nursing was not informed until the report was sent. The facility's investigation revealed that the Care Coach did not follow up with the resident on the evening of the incident, and the Director of Nursing confirmed that the incident was not initially identified as abuse. The lack of immediate reporting and failure to recognize the situation as potential abuse contributed to the deficiency, as the facility did not adhere to the required protocols for timely reporting and addressing allegations of abuse.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent prior to the initiation of bed rails for two residents. This deficiency was identified during a survey where Resident #120 was observed with bed rails in use, but a review of their medical record did not reveal a consent form for the bed rail use. The Director of Nursing (DON) explained that residents were assessed prior to the initiation of bed rails and that the consent could be found on the assessment form. However, upon review, the surveyor found no documentation of consent for Resident #120's bed rail use, and the Nursing Home Administrator (NHA) confirmed the absence of consent. Similarly, Resident #23 was observed with bed rails, and a review of their medical record also failed to reveal a consent form for the bed rail use. The DON reiterated the facility's process of assessment and consent documentation, but the surveyor again found no evidence of consent. The NHA confirmed that there was no consent for Resident #23's bed rail use. These findings indicate a failure by the facility to ensure that informed consent was obtained and documented prior to the use of bed rails for these residents.
Failure to Communicate Pharmacist Recommendations to Physicians
Penalty
Summary
The facility failed to ensure that pharmacists' recommendations regarding medication irregularities were communicated to the residents' physicians. This deficiency was identified during a survey for three residents who were reviewed for unnecessary medications. For Resident #51, the Director of Nursing (DON) was unable to provide the pharmacy report from November 2023, which contained potential irregularities and recommendations. The process described by the DON involved the pharmacist emailing the report to clinical management staff, who would then print and deliver it to the physician for review and signature. However, there was no documentation to confirm that the physician received or acted upon the pharmacist's recommendations. Similarly, for Resident #111, the DON could not provide the pharmacy review from October 2023, nor could she confirm whether any irregularities were addressed by the resident's physician. The same process was described, where the pharmacist's report was supposed to be reviewed and signed by the physician, but again, there was no documentation to verify that this occurred. The lack of documentation indicated a failure in the communication process between the pharmacist and the physician regarding medication irregularities. For Resident #117, the pharmacist's reports identified irregularities on three occasions, with recommendations for actions such as discontinuing duplicate medications and conducting specific tests. Although the reports were eventually provided, they were not part of the resident's medical record, and there was no documentation in the medical record to indicate that the attending physician reviewed or responded to the pharmacist's recommendations. This lack of documentation and communication highlights a systemic issue in ensuring that pharmacists' recommendations are properly addressed and documented in the residents' medical records.
Delayed Call Bell Response in LTC Facility
Penalty
Summary
The facility failed to respond timely to residents' call bells, as evidenced by a complaint involving a resident whose call bell went unanswered for 42 minutes or longer on multiple occasions. The complaint was reviewed during a recertification survey, revealing that the resident experienced delays on specific dates, with some instances occurring twice in a single day. Interviews with staff members, including a Geriatric Nursing Assistant (GNA) and a Licensed Practical Nurse (LPN), highlighted that the expectation was to answer call bells within 8 minutes, as communicated during staff meetings and orientation. However, the actual response times significantly exceeded this expectation. Further investigation revealed that the facility lacked a formal call bell policy. The Director of Nursing (DON) confirmed the absence of such a policy during an interview. The Nursing Home Administrator (NHA) and DON acknowledged the deficiency in call bell response times, confirming the delays and recognizing it as a deficiency. The report does not mention any corrective actions or follow-up measures taken to address the issue.
Failure to Protect Resident from Abuse by GNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a geriatric nursing assistant (GNA) and a resident who required assistance with transfers. The resident, who needed help moving from bed to wheelchair and back, requested assistance from GNA #15 to return to their room after lunch. The GNA refused to assist the resident, stating that she would help when she was ready, despite the resident expressing discomfort and a desire to return to their room. The GNA further dismissed the resident's request by telling them to be quiet and that they would be taken back after dinner. The resident attempted to wheel themselves back to their room, and other staff members noticed and assisted the resident. The incident was reported to the Assistant Director of Nursing the following morning. An interview with GNA #15 confirmed that she refused the resident's request for assistance and also prevented visitors from helping the resident. The Director of Nursing later substantiated the abuse, leading to the termination of the GNA.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. On January 9, 2023, a family member reported to a supervisor that the resident alleged abuse and retaliation by staff. The facility's investigation included interviews with staff members assigned to the resident during the time of the alleged abuse and some residents. However, the investigation lacked documentation of an interview with the family member who reported the allegation, the resident involved, and the supervisor who initially received the report. During a discussion on October 10, 2024, with the Director of Nurses (DON), it was revealed that these critical interviews were missing from the investigation. The DON acknowledged the concerns and expressed surprise that the interviews were not included. This oversight indicates a failure to conduct a comprehensive investigation into the abuse allegation, as essential interviews were not documented.
Failure to Notify Primary Care Provider of Lab Result
Penalty
Summary
The facility failed to notify a primary care provider of a lab result for a resident reviewed for urinary tract infections. On 9/20/24, a urine culture and sensitivity test for the resident was compromised as the specimen was spilled in transit. This incident was communicated to a Registered Nurse, identified as Staff #14. However, there was no documentation in the resident's medical record indicating that this information was communicated to the primary care provider. An interview with the Registered Nurse Care Coach/Unit Manager confirmed that it is the nurse's responsibility to review lab results and notify the primary care provider, as well as document the communication and the provider's response. The Director of Nursing was made aware of the failure to notify the provider of the lab result.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and well-repaired environment, as evidenced by several maintenance issues that were not addressed in a timely manner. On the Potomac Unit's 2nd floor, a housekeeping closet was found unlocked with a broken keypad lock, allowing access to cleaning supplies and hand sanitizers. This was confirmed by a registered nurse and the Director of Nursing, who acknowledged the deficiency. Additionally, a hole in the wall of a hallway bathroom was observed, which was stuffed with toilet paper. The Maintenance Director was unaware of the issue until it was pointed out during the survey. In two resident rooms, the drywall behind the beds was gouged, exposing the underlying surface. Despite multiple observations, the damage remained unaddressed. The Maintenance Director stated that work orders for non-emergent issues were processed through the front desk and tracked via a computer system. However, he was not aware of any work orders for the damaged drywall in these rooms and noted that repairs could not be completed while the rooms were occupied. Documentation showed previous repairs in other rooms, but no current work orders for the affected rooms were found.
Failure to Include Care Plan in Resident Transfer Documentation
Penalty
Summary
The facility failed to include the resident care plan with the required documentation during a transfer, as evidenced by the case of Resident #45, who was hospitalized on two occasions. During interviews with several Licensed Practical Nurses (LPNs), it was revealed that the nurses used a transfer checklist to ensure required documents were sent with the resident upon transfer. However, the review of the transfer form checklist did not indicate the inclusion of a care plan. Multiple LPNs confirmed that they would not send the resident's care plan upon transfer. The Director of Nursing (DON) acknowledged that the care plan should be sent with residents upon transfer, but this was not being practiced, leading to the deficiency.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of transfer to residents and their representatives, as required. This deficiency was identified for two residents who were hospitalized. For the first resident, the medical record review revealed that the resident was hospitalized on two occasions, but there was no evidence of a written transfer form being provided to the resident or their representative for these hospitalizations. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility typically did not provide written notices to residents and only verbally informed the representatives, which was not consistently documented. For the second resident, the medical record indicated a transfer to a hospital due to respiratory distress. Although there was documentation of the transfer and verbal notification to the resident's representative, there was no evidence that a written notice was provided to the resident or their representative. The NHA and DON acknowledged the deficiency, noting that while a transfer notice form was supposed to be completed and given to the resident and/or representative, it was not consistently done, and the documentation was not found in the medical records.
Failure to Prepare and Document Resident Transfers
Penalty
Summary
The facility failed to properly orient, prepare, and document the transfer of two residents to the hospital. For one resident, the medical record review revealed hospitalizations on two separate dates, but there was no documentation indicating that the resident was prepared and oriented for these transfers. The Director of Nursing (DON) confirmed that the facility used progress notes and a transfer form to document transfers, but the review of these documents did not show evidence of preparation and orientation for the resident. For another resident, the medical record indicated a transfer to an acute care facility due to respiratory distress. Although the SBAR communication documented the resident's condition and the physician's order for transfer, there was no evidence that the resident was informed about the reason for the transfer or that the resident's understanding was documented. The DON acknowledged these concerns when they were brought to her attention.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents and their representatives upon transfer to an acute care facility. This deficiency was identified during a review of medical records for two residents who were hospitalized. For one resident, the electronic medical record indicated a transfer to a hospital due to respiratory distress, but there was no documentation that the resident or their representative received written notice of the bed-hold policy at the time of transfer or within 24 hours in the case of an emergency. Interviews with the Nursing Home Administrator (NHA) and the Director of Nurses (DON) revealed that while verbal notifications were given, written notices were not consistently provided or documented in the residents' records. Similarly, for another resident who was hospitalized on two occasions, the facility failed to provide evidence of a written bed-hold policy notification. The NHA admitted that the policy notifications were not always given to residents and were not consistently uploaded into the electronic medical record, relying instead on verbal communication. Despite requests from the surveyor, the facility was unable to produce documentation of the written notifications for the resident's hospitalizations, highlighting a systemic issue in ensuring compliance with notification requirements.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive, resident-centered care plans for two residents during a recertification survey. For one resident, who was moderately cognitively impaired and had diagnoses including anxiety disorder and depression, the care plan did not include measurable goals and non-pharmaceutical interventions for managing psychosis. The resident was receiving psychotropic medications, including Quetiapine for hallucinations and psychosis, and Ativan for agitation, restlessness, and anxiety. Despite these treatments, the care plan only addressed potential complications from psychotropic drugs and lacked a comprehensive approach to the resident's condition. Another resident, who had a hearing aid, was found to have a care plan that failed to indicate the presence of the hearing aid. The Minimum Data Set (MDS) assessment had noted the hearing aid, but the care plan was not updated to reflect this information after the most recent care plan meeting. The Director of Nursing confirmed the deficiency, acknowledging that the care plan should have included the hearing aid information.
Unlicensed Feeding Assistance by Private Duty Aide
Penalty
Summary
The facility failed to ensure that only licensed staff fed residents, as observed during a recertification survey. On the 2nd floor Potomac Unit dining room, an unidentified female without a name badge was seen feeding a resident in a wheelchair, identified as Resident #39, who required feeding assistance. This individual was later identified as a private duty aide (PDA #2) hired for another resident, Resident #11. PDA #2 fed Resident #39 multiple times, leaving and returning to the table, while other facility staff were present in the dining area and hallways. Interviews conducted with a Geriatric Nursing Assistant (GNA #3) and the unit manager, a Registered Nurse (RN #1), confirmed that PDA #2 was not licensed and should not have fed Resident #39. The Director of Nursing (DON) explained that PDA #2 had been working with Resident #11 for over a year and was asked by Resident #11 to assist Resident #39. Despite the presence of other GNA staff who observed the incident, no intervention occurred. The DON acknowledged the deficiency and stated that PDA #2 should have informed the nurse or assigned GNA about Resident #39's need for assistance.
Inadequate Parameters for As-Needed Constipation Medications
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary medications by not providing adequate parameters for administering as-needed medications for constipation. During a review of the medical record for a resident, it was found that the September Medication Administration Record (MAR) included three medications prescribed as needed for constipation, with no clear guidelines on which medication to administer first. Two of these orders were for the same medication, Polyethylene Glycol Powder. The orders included lactulose oral solution to be taken every 12 hours as needed, Miralax Powder to be taken once a day as needed for no bowel movement, and Polyethylene Glycol Powder to be taken every 24 hours as needed. The lack of clear instructions in the physician orders led to confusion about which medication should be administered first for constipation relief. This issue was discussed with the Director of Nurses, who acknowledged the concern.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication by not adequately monitoring the resident for behavior, side effects, or adverse consequences related to psychotropic medication use. This deficiency was identified for one resident who was admitted to the facility following an acute hospitalization. The resident had moderate cognitive impairment, medically complex conditions, and multiple medical diagnoses, including dementia, anxiety disorder, and depression. The resident was prescribed an antipsychotic and an antidepressant, and received antipsychotics on a routine basis. The medical record review revealed that the resident was prescribed Duloxetine for depression, Quetiapine for hallucination and later for psychoses, and Lorazepam for restlessness, agitation, and anxiety. Despite orders to monitor the resident's behavior for agitation and mood decline, the facility failed to document specific behaviors or individualized, non-pharmacological approaches to care. Additionally, there was no documentation indicating that the resident was monitored for the specific behaviors for which the antipsychotic Seroquel had been prescribed. The Director of Nurses acknowledged these concerns during a discussion with surveyors.
Improper Food Storage Leading to Cross-Contamination Risk
Penalty
Summary
The facility failed to properly store food items to prevent cross-contamination, as observed during a survey. On one occasion, a surveyor found a sausage wrapped in plastic without a label or date in the walk-in freezer, which was subsequently removed by the Dining Services Supervisor. In another instance, a surveyor observed two metal containers in the second-floor kitchen of the Maryland unit. One container held red sauce, identified as salsa, without a cover or label, and the other contained an open bag of sour cream with a serving scoop inside. A dining server identified the items and removed them for disposal after being shown by the surveyor. The Dining Director acknowledged that the items should not have been left uncovered and unlabeled in the refrigerator.
Failure to Void Outdated MOLST Forms
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records by not voiding outdated Maryland Orders for Life Sustaining Treatment (MOLST) forms when new ones were created for residents. This deficiency was identified during a review of medical records for three residents, where it was found that each resident had multiple active MOLST forms with conflicting orders. For instance, one resident had an active MOLST form in their electronic medical record (EMR) indicating 'No CPR, Option B,' while their hard chart contained a different active MOLST form with 'No CPR, Option A-2.' Similar discrepancies were found in the records of the other two residents. The issue was brought to light during a survey when the surveyor requested copies of the active MOLST forms. The Nursing Home Administrator (NHA) acknowledged the concern and indicated that the MOLST forms were intended to be kept only in the paper chart, not in the EMR. The failure to void previous MOLST forms when new ones were created led to the presence of multiple active forms with conflicting orders in the residents' medical records.
Infection Control Deficiency: Foley Catheter Bag on Floor
Penalty
Summary
The facility failed to use appropriate infection control practices for a resident with an indwelling Foley catheter. During an observation, the surveyor noted that the resident's Foley catheter bag was lying flat on the floor. This observation was confirmed by a nurse, who acknowledged that the catheter bag should not be in contact with the floor. The nurse then adjusted the bed to ensure the catheter was no longer touching the floor, indicating that the bed had likely been lowered to its lowest position, causing the catheter bag to rest on the floor.
Failure to Educate on Pneumonia Vaccination Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents or their representatives were educated on the risks and benefits of pneumonia vaccinations. This deficiency was identified during a survey for two residents. For one resident, the immunization record indicated a refusal of consent for vaccines, but there was no documentation showing that the resident or their representative was informed about the health benefits and risks of receiving vaccinations. Similarly, another resident's representative refused a pneumococcal vaccination, yet there was no evidence of education provided regarding the risks and benefits of the vaccination. The Infection Preventionist nurse confirmed the lack of documentation for educational efforts in these cases.
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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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