Western Md Hospital Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hagerstown, Maryland.
- Location
- 1500 Pennsylvania Avenue, Hagerstown, Maryland 21742
- CMS Provider Number
- 215110
- Inspections on file
- 13
- Latest survey
- June 4, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Western Md Hospital Center during CMS and state inspections, most recent first.
A resident dependent on mechanical ventilation was disconnected during a transfer by two GNAs, leading to a deficiency in respiratory care. The GNAs, who were agency staff, were unaware of the need for a respiratory therapist's presence during such procedures. The incident highlighted a lack of proper training and orientation for agency staff in handling ventilator-dependent residents.
A facility failed to honor a resident's DNR order, resulting in CPR being administered despite the resident's MOLST form indicating otherwise. The resident was resuscitated and hospitalized, returning with chest tubes. Additionally, the facility did not document discussions about advanced directives for another resident, who was cognitively intact, leaving no evidence of the resident being informed of their rights. These deficiencies were identified during a survey, highlighting issues with communication and documentation of residents' wishes.
The facility failed to store food according to professional standards, with expired items found in the kitchen and improper date markings on thawing liquid eggs. Additionally, temperature logs for residents' personal food refrigerators were incomplete or showed temperatures outside the recommended range. A temporary halt in dietary staff duties during a COVID outbreak led to a lapse in monitoring, as per the facility's policy.
The facility did not include behavioral health training in their staff competencies, despite identifying that 23 to 34% of residents had such needs. A review of employee files confirmed the absence of this training, and the Director of Quality acknowledged the oversight.
The facility did not have a current written transfer agreement with a local hospital, which is essential for the timely transfer of residents needing medical care. The Director of Quality confirmed the absence of such an agreement, despite routine transfers occurring without incident.
A facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to a deficiency identified during a survey. A resident who relied on bed rails for mobility was found to have loose rails. The Maintenance Director admitted that regular inspections were not conducted, and the Director of Quality confirmed that inspections were not performed prior to the survey. Documentation of inspections was only completed after the survey began.
The facility failed to include an Infection Preventionist in six consecutive QAPI meetings from November 2023 to April 2024, despite a requirement for their attendance starting in January 2024. This was confirmed by the Director of Quality during an interview.
The facility failed to develop comprehensive care plans with measurable objectives for residents with seizure disorders, PTSD, dental issues, and pressure ulcers. A resident with a seizure disorder lacked a care plan addressing anticonvulsant use, while another with PTSD had no specific triggers identified. A resident experiencing tooth pain had no dental care plan, and a resident with a pressure ulcer lacked measurable wound care goals. Staff acknowledged these deficiencies during the survey.
The facility failed to provide written notice to two residents or their responsible parties before room changes, as required by policy. One resident with severe cognitive impairment experienced two room changes without prior written notification, despite disagreement from their responsible party. Another resident, who is alert and oriented, was moved without receiving written notice, although they verbally agreed to the change. Staff interviews revealed a lack of adherence to the requirement for written notification.
The facility failed to maintain a safe and homelike environment, with unresolved water stains and infrastructure damage observed in two nursing units. Despite having a system for reporting maintenance issues, no work orders were submitted for these deficiencies, as confirmed by the Maintenance Director.
The facility failed to include comprehensive care plan goals in the transfer documentation for two residents sent to the hospital, compromising the safe and effective transition of care. Staff confirmed that the transfer packets typically included progress notes, labs, and EKG results, but not the care plan goals.
The facility failed to provide written notifications of transfers to residents, their representatives, and the Ombudsman. Two residents were transferred to the hospital without receiving the required written notifications. Staff interviews revealed that notifications were typically done verbally, and the social work department did not include the Ombudsman in the notification process. The Nursing Home Administrator acknowledged the oversight.
A resident with severe cognitive impairment and dependence on staff for self-care did not receive consistent oral hygiene services as required. Observations revealed white secretions in the resident's mouth, and a review of care records showed multiple instances of undocumented oral care. The Unit Nurse Manager confirmed the lack of documentation, acknowledging the concern that oral care was not provided.
A facility failed to ensure GNAs were competent in caring for a resident on mechanical ventilation. The incident involved GNAs disconnecting the ventilator tubing during a transfer without respiratory staff supervision, revealing a gap in training and competency. Documentation showed signed competency forms but lacked detailed training content, and a blank orientation form indicated incomplete training implementation.
A resident with hypertension received an antihypertensive medication without adherence to the prescribed parameters, as the facility failed to document the required apical pulse before administration. The medication was given daily despite the absence of documentation for the necessary parameters, leading to a deficiency in medication administration.
The facility failed to store safety lancets in their original packaging with visible expiration dates and did not maintain proper refrigerator temperatures for medications, as observed in two nursing units. Medications such as Trulicity, Pneumococcal vaccine, and ASPART insulin were stored at temperatures below the manufacturer's recommended range.
A resident experienced frequent tooth pain, but the facility failed to update the care plan or secure a dental consult. Despite multiple staff documenting the resident's pain and need for dental care, no order for a dental appointment was found. The resident's pain was managed with temporary measures, but the underlying dental issues were not addressed in the care plan. Challenges in finding a dental provider for non-ambulatory residents contributed to the delay.
The facility failed to conduct a root cause analysis on deficiencies, leading to repeated issues such as not sending transfer notices to residents' representatives and not following physicians' orders. The facility's plan of correction was incomplete, and they failed to secure a transfer agreement with a local hospital. Additionally, the facility did not meet compliance dates for several deficiencies due to delayed staff education.
A resident with severe cognitive impairment was involved in an abuse allegation that was not reported to the state agency within the required timeframe. The NHA was informed of the allegation but delayed reporting it due to her absence from the facility, violating the policy that mandates timely reporting of such incidents.
The facility failed to document thorough investigations into abuse allegations for three residents. One resident reported maltreatment, but the facility could not provide investigation details. Another resident's abuse allegation during medication administration lacked supporting documentation, and a third resident's injury investigation did not include staff interviews. The facility's reports to OHCQ concluded no abuse, but documentation was insufficient.
A facility failed to implement physician orders for 15-minute safety checks for a resident with a history of depression and suicide attempts. The resident was found with a cord around their neck and was transferred for psychiatric evaluation. Despite an active order, the facility did not document the checks, indicating a lapse in care and monitoring procedures.
A facility failed to provide adequate care for a resident with a Stage 3 pressure ulcer. The resident's medical records lacked proper documentation and assessment of the ulcer, including its stage and measurements. The wound nurse admitted that wound measurements were not being conducted due to other responsibilities. Additionally, the care plan was not comprehensive, failing to specify the ulcer's location and stage, and inaccurately documented the schedule for skin assessments.
The facility failed to ensure that physicians reviewed and documented responses to pharmacy recommendations for two residents. One resident had multiple pain medications and a positive Cologuard test, while another had potential drug interactions affecting INR levels. The facility's policy lacked clear procedures for physician response, leading to the deficiency.
A resident with bipolar disorder was prescribed Mirtazapine, but the facility staff failed to monitor the resident for specific behaviors and side effects related to the medication. The unit nurse manager was unsure how the physician's orders for behavior monitoring were integrated into the EHR, leading to a lack of documentation and oversight.
The facility failed to maintain accurate medical records for residents, including missing documentation for prescribed treatments and improperly voided MOLST forms. A resident with contractures lacked documentation of palm protector use, while another's contracture management was not recorded. Additionally, a resident's MOLST was not voided correctly, leading to multiple active orders.
Failure to Ensure Safe Respiratory Care During Resident Transfer
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who was dependent on mechanical ventilation due to respiratory failure. The resident, who had a history of stroke and severe cognitive impairment, was observed to be disconnected from the ventilator during a transfer from bed to a recliner chair. This disconnection occurred when two geriatric nursing assistants (GNAs) were transferring the resident using a Hoyer lift, and the ventilator alarm sounded, alerting a respiratory therapist who reconnected the ventilator. The incident was documented by both the respiratory therapist and a nurse, who noted that the disconnection lasted approximately two minutes. The GNAs involved in the transfer were not aware that a respiratory therapist needed to be present during such procedures. One of the GNAs admitted to disconnecting the ventilator tubing, while the other GNA expressed reservations about the action but did not prevent it. The GNAs were agency staff, and one of them had been working at the facility for about three months without prior experience with ventilator-dependent residents. The facility's documentation revealed that the GNAs had not been adequately educated on the proper procedures for handling ventilator-dependent residents. The respiratory therapist and unit nurse manager confirmed that the GNAs were informed post-incident about the critical nature of keeping residents connected to ventilators, as these devices are essential for their breathing. The lack of proper orientation and training for agency staff contributed to the deficiency, as evidenced by the blank Nursing Service Orientation Topic Validation form in the employee file of one of the GNAs.
Failure to Honor Resident's DNR Order and Document Advanced Directive Discussions
Penalty
Summary
The facility failed to ensure that the resident's wishes for resuscitation were communicated effectively to staff, resulting in harm to a resident with a do not resuscitate (DNR) order. The resident, who was on a ventilator, became apneic and unresponsive, leading staff to initiate cardiopulmonary resuscitation (CPR) without verifying the resident's Medical Order for Life-Sustaining Treatment (MOLST) form. Despite the MOLST form indicating a DNR status, CPR was performed, and the resident was resuscitated and transferred to the hospital, where they remained for eight days and returned with chest tubes inserted in each lung. The facility also failed to document discussions regarding advanced directives for another resident, who was cognitively intact and had been residing in the facility for long-term care. The medical record review revealed no evidence that the resident had an advanced directive or that the facility periodically informed the resident of their right to formulate one. The social worker confirmed that discussions about the resident's right to formulate an advanced directive had occurred but were not documented in the medical record. These deficiencies were identified during a survey, highlighting the facility's failure to follow procedures for verifying code status and documenting discussions about advanced directives. The lack of proper communication and documentation led to the inappropriate administration of CPR to a resident with a DNR order and the absence of evidence that another resident was informed of their rights regarding advanced directives.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey of the kitchen. Surveyors noted expired food items in the walk-in freezer and refrigerator, including pureed turkey, semi-mac and cheese, semi-turkey, tropical fruit, mandarin oranges, and meatballs. The food service administrator, Staff #53, confirmed these items were expired and discarded them. Additionally, liquid eggs were found thawing without proper date markings, and an opened container of Ken's Italian dressing lacked an opening date. A dented can of diced pears was also found on the floor, which Staff #53 acknowledged should be discarded. The facility also failed to maintain proper temperature logs for refrigerators containing residents' personal food. The temperature logs for the 1 East resident refrigerator showed temperatures outside the recommended range on 26 out of 31 days. Furthermore, Resident #12's personal room refrigerator had incomplete temperature logs, with only 5 out of 31 days documented. The dietary staff was responsible for recording these temperatures, but there was a temporary halt in their duties during a COVID outbreak, leading to a break in monitoring. The facility's policy titled 'Resident Outside Food Storage on Unit' was reviewed, indicating that the Hostess service, referring to dietary staff, should maintain daily temperature logs and cleaning for resident personal food items. However, due to the COVID outbreak, dietary staff did not visit the units, resulting in a lapse in monitoring. An observation of Resident #9's room revealed a personal refrigerator with a lock but no temperature log, further highlighting the deficiency in maintaining proper food storage and monitoring practices.
Deficiency in Staff Competency for Behavioral Health Needs
Penalty
Summary
The facility failed to include necessary staff competencies in their facility-wide assessment, specifically omitting behavioral health training despite identifying that 23 to 34% of the resident population had behavioral health needs. On June 4, 2024, a review of the facility assessment revealed this oversight, and further examination of employee files showed no evidence of behavioral health training being provided. During an interview, the Director of Quality acknowledged the concern, admitting that the competencies listed did not cover the level and type of care needed for all identified resident populations.
Lack of Written Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a current written transfer agreement with a local hospital, which is necessary to ensure residents can be moved quickly for medical care when needed. During a review conducted on June 4, 2024, it was found that the facility's assessment did not include a written agreement with a local hospital willing to accept residents from the facility. In an interview, the Director of Quality acknowledged the absence of such an agreement, although she noted that residents had been routinely transferred to the local hospital without incident. No additional documentation was provided to support the existence of a transfer agreement before the survey concluded.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, which led to a deficiency identified during a survey. This was particularly evident in the case of a resident who had been in the facility since 2016 and relied on bed rails for mobility due to weakness in the left arm. During an interview, the resident demonstrated the use of the bed rails, which were found to be loose. The Unit Nurse Manager acknowledged that assessments related to bed rails were documented in both electronic and hard copy records, but there was no documentation of regular inspections for bed safety. The Maintenance Director admitted that regular inspections of bed rails were not conducted, as he was only called upon by the Nursing department for installation or removal of bed rails. Despite the Nursing Home Administrator's claim of having conducted inspections with the Maintenance Director, documentation to support this was not initially provided. The Director of Quality later confirmed that inspections were not performed prior to the survey, and the documentation presented was completed only after the survey began. The deficiency was discussed with facility staff during the survey exit conference, but no further comments or documentation were provided.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to establish a Quality Assurance and Performance Improvement (QAPI) committee that included an Infection Preventionist at every meeting, as required. The deficiency was identified through a review of attendance sign-in sheets for QAPI meetings held from May 2023 through May 2024. It was found that the Infection Preventionist did not attend six consecutive meetings on specific dates from November 2023 to April 2024. During an interview, the Director of Quality confirmed the absence of the Infection Preventionist at these meetings and noted that the requirement for their attendance at every meeting began in January 2024.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans with measurable objectives and timeframes for several residents, leading to deficiencies in addressing their medical needs. For Resident #6, who had a seizure disorder and was on anticonvulsant medications, the care plan lacked measurable goals to manage the condition effectively. Despite having physician orders for seizure precautions, the care plan did not reflect these needs, which was acknowledged by the unit nurse manager. Resident #34, diagnosed with dementia, depression, and PTSD, had a care plan that was not person-centered. The plan failed to identify specific triggers that could re-traumatize the resident, despite the severe cognitive impairment documented in the MDS assessment. The care plan's goal was vague, stating that the resident would not experience PTSD triggers, but it lacked detailed interventions to prevent such occurrences, as noted by the unit nurse manager and assistant director of nursing. Resident #9 experienced frequent tooth pain, which was documented in the MDS assessment and medical records. However, the care plan did not address the dental issues or the need to find a dentist, despite multiple notes indicating the resident's discomfort. Similarly, Resident #24, who had a pressure ulcer, had a care plan that lacked measurable objectives and timeframes for wound care. The wound nurse admitted to not measuring wounds due to time constraints, which contributed to the inadequate care planning for the resident's pressure ulcer.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice to residents or their responsible parties before making room changes, as required by policy. This deficiency was identified for two residents during the survey. Resident #31, who has severe cognitive impairment due to dementia, experienced two room changes without prior written notification to their responsible party. The responsible party did not agree with the second room change, yet the move proceeded without documented discussion or resolution of their concerns. The facility's policy mandates a 30-day written notice and an interdisciplinary team meeting if there is disagreement about a room change, but these steps were not documented in Resident #31's case. Similarly, Resident #9, who is alert and oriented but dependent on staff for mobility, was moved to a new room without receiving written notice. Although the resident verbally agreed to the move after a discussion with the social worker, there was no documentation of written notice being provided, including the reason for the change. Interviews with staff, including the Nursing Home Administrator and the social worker, revealed a lack of awareness and adherence to the requirement for written notification, indicating a systemic issue in the facility's process for handling room changes.
Facility Fails to Address Maintenance Issues
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as evidenced by the presence of water stains and damaged infrastructure in two nursing units. On May 20, 2024, a surveyor observed water stains on the ceiling above a resident's bed in room K on unit 1 East, and a cracked wall protector below the handrail across from room E on unit 1. Despite the facility's protocol for reporting and addressing maintenance issues through an electronic work order system, these deficiencies were not addressed. During a follow-up tour on May 31, 2024, with the Maintenance Director, the previously identified issues remained unresolved, and an additional water stain was noted on a ceiling tile in the 1 East hallway. The Maintenance Director acknowledged the presence of a chiller pipe with bad insulation above the ceiling in room K but indicated there was no feasible permanent solution. Furthermore, the Maintenance Director confirmed that no work orders had been submitted for the identified areas, highlighting a lapse in the facility's maintenance and repair processes.
Failure to Communicate Care Plan Goals During Resident Transfers
Penalty
Summary
The facility failed to communicate the comprehensive care plan goals of residents to the receiving healthcare institution during transfers, which is a requirement for ensuring safe and effective transitions of care. This deficiency was identified for two residents who were reviewed for hospitalizations. Resident #24, who had been residing in the facility since 2020, was sent to the hospital twice in 2024. During an interview, a Registered Nurse (RN) described the process for preparing documentation for a resident's transfer, which did not include care plan goals. The unit nurse manager confirmed that the transfer packet did not contain care plan goals, highlighting a gap in the communication process. Similarly, for Resident #19, who experienced a change in condition and was transferred to the hospital, the medical record review revealed that the transfer documentation did not include the resident's comprehensive care plan goals. The unit nurse manager acknowledged that the transfer packet typically included progress notes, labs, and EKG results, but not the care plan. This oversight in documentation and communication was discussed with the unit nurse manager, emphasizing the facility's failure to ensure the safe and effective transition of care for residents being transferred to other healthcare institutions.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of transfers to residents, their representatives, and the Office of the State Long-Term Care Ombudsman, as required. This deficiency was identified during a review of medical records and staff interviews, specifically affecting two residents who were hospitalized. Resident #19 experienced a change in condition and was transferred to the hospital without receiving written notification of the transfer. The Licensed Social Worker (SW) acknowledged that written notifications were only sent to the resident's representative if the resident remained out of the facility for more than 24 hours, and that the Ombudsman was not notified. Similarly, Resident #24 was transferred to the hospital twice in 2024 without written notifications being sent to the resident, their representative, or the Ombudsman. Interviews with nursing staff and the Unit Nurse Manager revealed that notifications were typically done verbally, and written notifications were handled by the social work department. However, the social worker confirmed that the Ombudsman was not included in the notification process. The Nursing Home Administrator was informed of this oversight and acknowledged the concern.
Failure to Provide Oral Hygiene to Dependent Resident
Penalty
Summary
The facility failed to provide necessary oral hygiene services to a resident who was unable to perform activities of daily living independently. The resident, who had been residing in the facility since 2016, was observed with white secretions in the mouth, indicating poor oral care. The resident's Minimum Data Set (MDS) assessment revealed severe cognitive impairment and dependence on staff for self-care, including oral hygiene. Despite the resident's needs, the facility did not consistently document the provision of oral care as required. A review of the resident's orders indicated that oral care was to be administered four times daily. However, the administration history from late April to late May showed numerous instances where oral care was not documented, including several days where no care was recorded at all. The Unit Nurse Manager confirmed the lack of documentation and acknowledged the concern that oral care was not provided to the dependent resident, emphasizing the nursing principle that if care is not documented, it is considered not done.
Inadequate Competency in Ventilator Care
Penalty
Summary
The facility failed to ensure that geriatric nursing assistants (GNAs) were competent in providing care to a resident dependent on mechanical ventilation. This deficiency was identified during a review of an incident involving a resident who was admitted with a history of stroke and respiratory failure, requiring mechanical ventilation. The resident, who had severe cognitive impairment and was non-verbal, was involved in an incident where GNAs disconnected the ventilator tubing during a transfer without the presence of a respiratory therapist. The incident occurred when two agency GNAs attempted to transfer the resident using a hoyer lift, during which the ventilator tubing was disconnected. A respiratory therapist discovered the disconnection upon responding to a ventilator alarm. The GNAs involved were not aware that they should not disconnect the ventilator or transfer the resident without respiratory staff supervision. One of the GNAs admitted to not understanding the difference between ventilator and tracheostomy care, highlighting a gap in their training and competency. Documentation revealed that the GNAs had signed competency forms indicating they were trained in respiratory care, but the forms lacked detailed descriptions of the training content. Additionally, a blank Nursing Service Orientation Topic Validation form was found in the employee file of one of the GNAs, indicating that the necessary orientation and training had not been fully implemented prior to the incident. This lack of proper training and competency assessment led to the deficiency in care provided to the resident.
Failure to Follow Medication Administration Protocol for Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that a resident received medication according to the attending physician's orders, leading to a deficiency in medication administration. Resident #32, who was admitted in December 2022 with a diagnosis of hypertension, had an order for an antihypertensive medication to be administered twice daily. The order included specific parameters to hold the medication if the systolic blood pressure (SBP) was less than 100 mmHg or the apical pulse was less than 55 beats per minute. However, the medication administration records (MARs) for April and May 2024 showed that the resident received the medication daily without documentation of these parameters. Further investigation revealed that the vital signs history for the resident during this period only contained records of the radial pulse and not the apical pulse, which was required by the physician's order. Interviews with staff members, including licensed practical nurses and the assistant director of nursing (ADON), confirmed that the apical pulse was not documented as required. The ADON acknowledged the oversight and noted that the nurses were supposed to check the apical pulse instead of the radial pulse, indicating a failure in following the prescribed medication administration protocol.
Improper Storage of Medical Devices and Medications
Penalty
Summary
The facility failed to properly store medical devices and medications according to the manufacturer's guidelines, as observed during a survey. On two separate nursing units, safety lancets were found outside of their original packaging, with no visible expiration dates. Nurse Supervisor Staff #13 confirmed that the lancets were not stored in their original boxes and was unable to provide expiration dates. Additionally, a large quantity of safety lancets was discovered in a wall cabinet, also without original packaging or known expiration dates. Furthermore, the facility did not maintain appropriate refrigerator temperatures for medication storage. Observations revealed that the medication refrigerator in the [NAME] Wing had a temperature reading between 30 and 32 degrees Fahrenheit, which is below the manufacturer's recommended storage temperature for several medications, including Trulicity, Pneumococcal 20-valent Conjugate vaccine, and ASPART insulin. Despite adjustments made by the Maintenance Director, the temperature remained below the required range. The facility's policy mandates that medications be stored according to the manufacturer's instructions, which was not adhered to in this case.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to ensure that a dental care plan and appropriate orders were in place for a resident experiencing frequent tooth pain. The resident, who had been living at the facility for several years, was alert, oriented, and dependent on staff for mobility. Despite the resident's repeated complaints of tooth pain, documented by various staff members, there was no order for a dental consult or a care plan addressing the dental issues. The resident's medical record showed multiple instances where staff documented the resident's tooth pain and the need for a dental consult. However, the care plan was not updated to reflect these dental concerns, and no order for a dental appointment was found. The resident's pain was managed temporarily with Anbesol gel and acetaminophen, but the underlying dental issues were not addressed in the care plan. Interviews with staff revealed challenges in finding a dental provider for non-ambulatory residents. Although a provider was eventually identified, and an appointment was scheduled, the delay in addressing the resident's dental needs and updating the care plan constituted a deficiency in the facility's care planning process.
Recurrent Deficiencies and Compliance Failures
Penalty
Summary
The facility failed to conduct a root cause analysis on deficiencies cited during a recertification survey, leading to the recurrence of the same issues. During a revisit survey, it was found that the facility did not send transfer notices to residents' representatives as required, and staff failed to follow physicians' orders for medication administration. The facility's plan of correction focused only on specific orders, neglecting to address all physician orders. Additionally, the facility did not effectively implement a plan of correction for care plan evaluations, as social workers, who were not qualified to evaluate care plans, were tasked with this responsibility. The facility also failed to secure a transfer agreement with a local hospital, despite stating they would make a good faith attempt by a specified date. Furthermore, the facility did not meet its alleged compliance date for several deficiencies, including unnecessary medications and medication storage, as staff education was not completed on time. Interviews with facility staff revealed a lack of timely intervention and education for certain staff members, contributing to the failure to meet compliance deadlines.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility staff failed to report an allegation of abuse involving a resident with severe cognitive impairment in a timely manner. The resident, admitted in August 2022 with a diagnosis of dementia, was the subject of an abuse allegation reported to the Nursing Home Administrator (NHA) on February 7, 2024, at approximately 4:20 PM. However, the NHA did not report the allegation to the state agency until February 9, 2024, which was beyond the required timeframe for reporting such incidents. The facility's policy mandates that allegations of abuse must be reported to the appropriate agencies within 24 hours, or within 2 hours if serious bodily injury or abuse is alleged. Despite this policy, the NHA confirmed during an interview that the report was delayed because she was not present in the building when the allegation was initially reported to the social worker. This delay in reporting constitutes a failure to adhere to the facility's own procedures and regulatory requirements for timely reporting of abuse allegations.
Failure to Document Thorough Abuse Investigations
Penalty
Summary
The facility failed to provide documentation of thorough investigations into allegations of abuse for three residents. Resident #98 reported maltreatment by a staff member, but the facility could not provide any employee statements or resident interviews that comprised the investigation. The current administrator, who was not in position at the time of the investigation, was unable to locate the investigation file. Similarly, for Resident #9, who reported an abuse allegation during medication administration, the facility's documentation lacked evidence of interviews with staff or residents, and the full name of a witness was not identified. The final report submitted to the Office of Health Care Quality (OHCQ) concluded no evidence to substantiate the allegation, but supporting documentation was insufficient. For Resident #15, who had a blister of unknown origin, the facility's investigation concluded that abuse was not substantiated, and a police report indicated no criminal investigation was required. However, the facility failed to provide documentation of staff interviews conducted during the investigation. The resident was unable to report how the blister occurred, and the facility's documentation did not include evidence of a thorough investigation. The surveyor reviewed these concerns with the Director of Nursing and the Nursing Home Administrator, highlighting the facility's failure to document comprehensive investigations into the allegations.
Failure to Implement 15-Minute Safety Checks for Resident
Penalty
Summary
The facility failed to implement physician orders for 15-minute safety checks for a resident with a history of depression and previous suicide attempts. The resident was discovered with a cord wrapped around their neck and was subsequently transferred to a local hospital for psychiatric evaluation. Despite having an active physician order for 15-minute safety checks, the facility did not document these checks in the nursing binder or the electronic health record during the time the order was in place. The administrator acknowledged the lack of documentation and stated that the facility had transitioned to recording 15-minute safety checks in the electronic health record. However, no documentation was provided for the required checks during the specified period, indicating a failure to adhere to the physician's orders and ensure the resident's safety. This deficiency was identified during a survey, highlighting a significant lapse in the facility's care and monitoring procedures for residents with behavioral or emotional care needs.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice to prevent the development of pressure ulcers and promote healing of existing pressure ulcers for a resident. The resident had a Stage 3 pressure ulcer on the left lower buttock, which was not properly documented or assessed. The facility's electronic medication administration record (eMAR) showed inconsistencies in the administration of prescribed treatments, with a missed application of a moisture barrier cream and incorrect scheduling of skin assessments. The medical record review revealed that the facility did not document the stage of the pressure ulcer or conduct regular wound measurements, which are essential for monitoring the healing process. The wound nurse, responsible for initial wound assessments and guiding staff on wound treatments, admitted that wound measurements were not being done due to her other responsibilities. This lack of consistent wound measurement and documentation was a significant oversight in the resident's care. Additionally, the resident's care plan was not comprehensive or resident-centered, failing to specify the location and stage of the pressure injury. The care plan inaccurately documented the schedule for skin assessments, which did not align with the actual practice. The facility's failure to conduct ongoing assessments and revise the care plan based on the resident's changing needs put the resident at risk for impaired wound healing.
Failure to Document Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during monthly drug regimen reviews were reviewed by the attending physician, and that the physician documented the review and any actions taken in the medical record. This deficiency was observed in two residents. For Resident #6, the pharmacist identified several irregularities, including the use of multiple pain medications and the need for a PPI due to a positive Cologuard test and the use of Eliquis. Despite these recommendations, there was no documentation in the resident's medical record indicating that the attending physician reviewed or addressed these issues. Similarly, for Resident #9, the pharmacist noted potential drug interactions between ibuprofen and warfarin, which could affect the resident's INR levels. The pharmacist recommended discontinuing ibuprofen and considering alternative pain therapies. However, the medical record lacked documentation that the primary care provider reviewed or addressed these recommendations. Interviews with staff revealed that the facility had inconsistent procedures for notifying physicians of pharmacy recommendations, contributing to the lack of documented responses. The facility's Drug Regimen Review policy did not specify a timeframe for physicians to respond to pharmacist recommendations or require documentation of the response in the medical record. This lack of clear procedures and documentation led to the deficiency, as the facility failed to ensure that physicians reviewed and addressed monthly pharmacy recommendations, as evidenced by the cases of Residents #6 and #9.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by not adequately monitoring a resident for behavior, side effects, or adverse consequences related to the use of psychotropic medication. This deficiency was identified for a resident who had been in the facility for long-term care since February 2020 and had a diagnosis of bipolar disorder. The resident was prescribed Mirtazapine, an antidepressant, to be taken daily. However, there was no documentation in the resident's medical record indicating that the facility staff conducted ongoing monitoring for the specific behaviors for which the psychotropic medication was prescribed or for any side effects of the medication. During an interview, the unit nurse manager acknowledged that the physician wrote the order for the psychotropic medication and behavior monitoring, but she was unsure how this was integrated into the electronic health record. The nurse manager indicated that the order should automatically populate into the resident's administration record for nurses to document accordingly. Despite being made aware of the concerns regarding the lack of monitoring for behavior and potential side effects, the nurse manager did not provide further explanation.
Deficiencies in Medical Record Documentation and Order Management
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, as evidenced by the survey findings. Resident #6, who had been residing in the facility since February 2020, was observed with hand contractures but without the prescribed palm protectors. The electronic medication administration record (eMAR) lacked documentation of the application of these protectors from May 1 to May 22, 2024, despite an order from September 2022. Additionally, there was an incomplete order for Silver Nitrate, lacking specific application instructions, which was acknowledged by the unit nurse manager. Resident #21, diagnosed with spastic quadriplegic cerebral palsy and contractures, was observed without the necessary splints or devices. The eMAR for May 2024 did not document the application of pillow rolls/bolsters as ordered for contracture management. The Therapy Services Manager and Restorative Nurse/MDS Coordinator noted limitations in the EHR software that hindered accurate documentation. Furthermore, an order for a mineral oil rectal enema lacked a clear indication for administration, which was recognized as a concern by the staff. Resident #96's chart contained multiple Maryland Orders for Life-Sustaining Treatment (MOLST), with a prior MOLST not properly voided according to protocol. The Medical Director confirmed the presence of more than one MOLST and acknowledged the incorrect voiding of the old MOLST. These deficiencies highlight issues in documentation and adherence to medical orders within the facility.
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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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