Tuckerman Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Bethesda, Maryland.
- Location
- 5550 Tuckerman Lane, North Bethesda, Maryland 20852
- CMS Provider Number
- 215320
- Inspections on file
- 15
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Tuckerman Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents were discharged without appropriate reasons or proper documentation. One resident with terminal cancer was told hospice care could not be provided at the facility, despite the admission contract stating otherwise, and the family was not informed of service limitations. Another resident with advanced dementia was discharged due to poor rehab participation and the need for a memory care unit, but there was no documentation that the facility could not meet their needs. In both cases, regulatory requirements for discharge were not met, and staff interviews confirmed discharges were based on therapy participation rather than regulatory criteria.
The facility did not provide the required 30-day written discharge notices to two residents who were being discharged, instead issuing only a Notice of Medicare Non-Coverage (NOMNC). In both cases, the discharges were initiated by the facility due to changes in care needs, and interviews confirmed that neither resident nor their representatives received the mandated 30-day notice explaining the reason for discharge.
A resident's representative requested that the resident remain in the facility to receive hospice care, but staff informed the representative that hospice could not be provided on-site and proceeded with discharge plans. Despite the facility having a contract with a hospice provider and being capable of providing hospice services, staff preferred to discharge residents needing hospice or LTC. The representative appealed the discharge and attempted to find alternative placement, but ultimately felt pressured to take the resident home.
A resident was administered quetiapine and PRN lorazepam for behavioral symptoms without proper documentation of behavior monitoring, nonpharmacological interventions, or attempts at gradual dose reduction. The PRN psychotropic order lacked a required 14-day stop date, and the consent for psychotropic use was signed on admission without evidence of exhausted nonpharmacological approaches. Staff interviews confirmed inadequate documentation and inappropriate diagnoses for medication use.
A resident with advanced cancer diagnoses and in need of end-of-life care was admitted for rehabilitation, but neither the resident nor their representative was informed in writing that the facility did not provide hospice or LTC services. The facility's admission materials did not disclose these limitations, and the family was only verbally notified when discharge planning for hospice was initiated.
The facility did not complete thorough investigations into two separate abuse allegations, as required. In both cases, the DON confirmed that neither staff nor resident interviews or statements were obtained or documented as part of the investigation.
Inappropriate Discharge and Inadequate Documentation for Two Residents
Penalty
Summary
The facility discharged two residents without appropriate reasons and failed to properly document the discharges, as required by regulation. For one resident with metastatic skin cancer and multiple comorbidities, the facility issued a Notice of Medicare Non-Coverage (NOMNC) and informed the family that hospice care could not be provided at the facility, despite the admission contract stating hospice care was available. The family was not informed of any service limitations at admission and expressed concerns about the discharge, especially since the resident’s spouse had dementia and could not provide adequate care at home. The facility staff, including the Social Services Director (SSD) and Director of Nursing (DON), stated the resident was being discharged due to the need for hospice care, but there was no documentation that the resident met any regulatory criteria for facility-initiated discharge. The facility also failed to provide documentation supporting their claim that the discharge was family-initiated. For the second resident, who had advanced dementia and severe cognitive impairment, the facility issued a NOMNC and planned for discharge due to poor participation in rehabilitation and the need for a memory care unit. The attending physician noted the resident was not a good candidate for the facility’s short-term rehabilitation program, but there was no documentation that the facility was unable to meet the resident’s needs or that the resident met the regulatory requirements for discharge. The family was not made aware of any limitations in the facility’s services and struggled to find an appropriate placement due to a pending Medicaid application. Interviews with facility staff confirmed that discharges were often initiated when residents plateaued in therapy or were no longer participating, regardless of whether regulatory discharge criteria were met. The facility’s admission contract and agreements with hospice providers indicated that hospice care could be provided, contradicting staff statements to families. The lack of proper documentation and failure to meet regulatory requirements for discharge were confirmed by the Nursing Home Administrator and DON during the survey.
Failure to Provide Required 30-Day Discharge Notices
Penalty
Summary
The facility failed to provide a required 30-day written notice of discharge to two residents who were being discharged from the facility. In the first case, the Social Services Director (SSD) attempted to issue a Notice of Medicare Non-Coverage (NOMNC) to the resident's family, indicating the end of Medicare Part A coverage and a planned discharge date. However, the family declined to sign the NOMNC, and the SSD explained that the facility could not provide hospice care. Despite this, there was no documentation that a 30-day written discharge notice, including the reason for discharge, was provided to the resident or their representative. The resident's representative confirmed that they did not receive such notice and only received the NOMNC, which was confusing as the resident still had Medicare days remaining. The SSD and DON both confirmed that the discharge was initiated by the facility due to the need for hospice care, not by the family, and that the required 30-day notice was not issued. In the second case, the SSD documented issuing a NOMNC to the family of another resident, with services ending shortly thereafter and a discharge to the community planned. The family appealed the NOMNC, but there was no evidence in the medical record that a 30-day discharge notice was provided to the resident's representative. Interviews with the NHA, DON, and SSD confirmed that the resident was discharged because it was determined they would benefit from a memory care unit, and that only the NOMNC was issued, not the required 30-day discharge notice. These findings were reviewed with facility leadership.
Failure to Honor Resident Representative's Request for Hospice Care
Penalty
Summary
The facility failed to honor the wishes of a resident's representative by not allowing the resident to remain at the facility while receiving hospice services. The resident's representative was informed by the Social Services Director (SSD) that the facility would discharge the resident because they could not provide hospice care on-site, despite the representative's request for the resident to stay and receive hospice care. The representative appealed the discharge twice and attempted to find another facility, but was denied due to the resident's wound care needs. Ultimately, the representative felt pressured by staff to take the resident home. Medical record review showed that the SSD attempted to issue a Notice of Medicare Non-Coverage (NOMNC), but the family did not sign it, and the SSD reiterated that hospice care could not be provided at the facility. A review of the facility's contract with a hospice provider revealed that the facility did have an agreement in place to provide hospice services to residents. Interviews with the SSD, DON, and Nursing Home Administrator confirmed that the facility preferred to discharge residents who required hospice or long-term care, even though they were capable of providing hospice services. The DON and NHA both stated that residents were discharged when they needed hospice care, and the NHA confirmed that the facility would only provide hospice care for a few days before discharging the resident to another setting. The facility was dually certified for rehabilitation and long-term care, but did not honor the resident representative's request for continued care with hospice services.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
Facility staff failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as well as to limit PRN psychotropic medications to 14 days. For one resident reviewed for discharge, the medical record showed ongoing administration of quetiapine for sundowning and lorazepam as needed for anxiety, with both medications continued for several months. The informed consent for psychotropic use was signed on the day of admission, stating that all nonpharmacological interventions had been exhausted, but there was no evidence that such interventions were attempted or documented prior to medication administration. Physician orders for the resident included lorazepam PRN without a 14-day stop date and quetiapine with an increased dosage for a diagnosis that was not appropriate. There was no documentation of behavior monitoring or attempts at gradual dose reduction for these medications. The psychiatric NP documented continued use of quetiapine for behavior modification, but behavior notes did not reflect monitoring of the targeted behaviors. The medication administration record showed multiple administrations of lorazepam by the same RN, with no documentation of the reasons for administration or nonpharmacological interventions attempted beforehand. Interviews with facility staff, including the attending physician, RN, and DON, confirmed that documentation was lacking regarding the behaviors leading to medication use and the use of nonpharmacological interventions. The DON acknowledged that the consent form was not appropriate and that behavior monitoring and documentation were not adequately performed. The staff also recognized that the PRN order for lorazepam should have included a 14-day stop date, and that the diagnosis for quetiapine was not appropriate.
Failure to Disclose Service Limitations for Hospice and Long-Term Care
Penalty
Summary
The facility failed to inform residents and their representatives about limitations in the care services provided, specifically regarding the inability to provide hospice or long-term care. A review of the admission packet signed by a resident showed that hospice services were listed as provided, and there was no indication of any service limitations. The facility's documentation did not state that residents would be discharged if they required hospice or long-term care, nor did it clarify that only rehabilitation services were offered. Interviews revealed that the resident's representative was not informed at admission about these limitations and only learned of them when the facility initiated discharge planning after the resident's condition declined and hospice care was needed. The resident in question had multiple serious diagnoses, including metastatic cancers and was considered to be at end-of-life shortly after admission. Despite this, the facility proceeded with discharge planning for hospice care, informing the family that the resident could not remain at the facility for hospice services. The Social Services Director and Nursing Home Administrator confirmed that residents needing hospice or LTC were assisted in finding new placement, but this was not documented in the admission materials and was only communicated verbally. The attending physician also confirmed that such residents were transferred elsewhere, further evidencing the lack of written disclosure to residents and their representatives.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse for two residents. In the first case, the facility's investigation into an abuse allegation did not include interviews with staff or the collection of staff statements. The Director of Nursing (DON) confirmed during an interview that these steps were not completed and was unable to locate any staff interviews or statements related to the incident. In the second case, the investigation into another abuse allegation similarly lacked interviews with both residents and staff, as well as the collection of their statements. The DON again confirmed the absence of these critical investigative components and was unable to provide any documentation of interviews or statements when requested by the surveyor.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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