Willowbrooke Ct Skilled Care Buckingham's Choice
Inspection history, citations, penalties and survey trends for this long-term care facility in Adamstown, Maryland.
- Location
- 3200 Baker Circle, Adamstown, Maryland 21710
- CMS Provider Number
- 215329
- Inspections on file
- 15
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Willowbrooke Ct Skilled Care Buckingham's Choice during CMS and state inspections, most recent first.
The facility inaccurately coded MDS assessments for several residents, misidentifying grab bars as restraints and incorrectly documenting a fall injury. Observations and interviews revealed a misunderstanding in coding practices, impacting the accuracy of resident assessments.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing specific needs such as hearing aid assistance, pain management, chronic constipation, and the use of grab bars. A resident with impaired hearing did not receive necessary assistance with hearing aids, while another resident's pain management needs were not formally addressed in a care plan. Additionally, a resident with chronic constipation and another using grab bars for mobility lacked appropriate care plans, highlighting gaps in the facility's care planning process.
The facility failed to deliver food at appropriate temperatures, as observed during a test tray temperature check. Breakfast items were served below the standard temperature due to the use of an open steel cart for transportation, which was chosen because closed carts were too heavy. This issue was noted during breakfast service for the Skilled Nursing Unit, with the Regional CDM confirming the inappropriate practice.
A surveyor found expired and unlabeled food items in the Skilled Nursing Unit kitchen, confirmed by staff. The Regional CDM was informed, and the facility planned to implement inspection reports to ensure proper food storage. The NHA and DON were notified.
A resident at high risk for wandering eloped from a facility due to inadequate door security. The resident exited through an unlocked door not part of the skilled unit, despite the Wander Guard system in place. The door alarm sounded, but the resident was found outside by security, having sustained a minor injury. Interviews revealed the door locked from the outside but not the inside, contributing to the incident.
The facility failed to conduct quarterly care plan meetings and update care plans for two residents. One resident's family was not invited to meetings, and documentation was lacking. Another resident's care plan was outdated, inaccurately reflecting a previous condition. The Registered Dietitian confirmed the care plan was not updated to reflect the current condition.
Inaccurate MDS Coding for Restraints and Fall Injuries
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, specifically regarding the use of 1/8 grab bars and the status of a resident after a fall. For five residents, the MDS assessments inaccurately identified bedrails as physical restraints, despite physician orders and care plans indicating their use as mobility aids. Observations confirmed the use of grab bars for mobility, yet the MDS records incorrectly documented them as restraints. Additionally, the facility inaccurately coded a resident's fall incident in the MDS assessment. The resident experienced a fall resulting in a skin tear, but the discharge MDS assessment inaccurately recorded the incident as having no injury. The MDS nurse acknowledged the error, indicating reliance on incident reports and related documentation for coding, which led to the oversight. Interviews with the MDS Coordinator and the Director of Nursing revealed a misunderstanding in coding practices, as they believed no residents were on restraints and that bedrails were used solely for mobility. The Director of Nursing was informed of the inaccuracies, highlighting a need for accurate assessment and documentation to ensure proper resident care.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #233, who was admitted with impaired hearing, was observed having difficulty hearing due to the lack of assistance with hearing aids. Although the resident's baseline care plan noted a communication problem related to hearing deficit, it did not include specific interventions for the use of hearing aids, which was confirmed by the Director of Nursing (DON) as a necessary inclusion. Resident #230 reported experiencing back pain that was relieved by Tylenol, yet there was no care plan developed to address this pain management need. The resident's clinical record showed the administration of Gabapentin and Tylenol for pain, but the absence of a formal care plan for pain management was acknowledged by the DON. Similarly, Resident #5 had a history of chronic constipation and was receiving medications like MiraLAX and Colace, but this condition was not included in the resident's care plan, as confirmed by the Assistant Director of Nursing (ADON). Additionally, Resident #23 was using bilateral grab bars for bed mobility and repositioning, as indicated in the resident's orders and MDS assessments. However, there was no care plan developed to address the use of these grab bars until after surveyor intervention. The MDS Coordinator stated that care plans should be created when a Care Area Assessment (CAA) is triggered, but this was not done for Resident #23 until the deficiency was pointed out by the surveyor.
Inadequate Food Temperature Control
Penalty
Summary
The facility failed to ensure that food was delivered to residents at an appropriate and palatable temperature. This deficiency was identified during an observation of a test tray temperature, which revealed that the food was not at the correct temperature when served. Specifically, the cream chipped beef was measured at 110.4°F, and the cream of wheat was at 123.9°F, both of which are below the standard serving temperature. The cold milk was at 41°F, which was within the acceptable range. The issue was observed during the breakfast service for the Skilled Nursing Unit, where the meal schedule was not adhered to, resulting in a delay in serving breakfast. The deficiency was attributed to the method of transporting the food trays from the Assisted Living kitchen to the Skilled Nursing Unit. The trays were initially placed in an open steel cart, which was not appropriate for maintaining the food temperature. The staff used the open cart because the closed carts were reportedly too heavy to transport between floors. This practice was confirmed by the Regional Certified Dietary Manager, who was temporarily assisting the facility due to the recent resignation of the facility's Certified Dietary Manager. The deficiency was reported to the Nursing Home Administrator and the Director of Nursing during the exit conference.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly store and label food items in the Skilled Nursing Unit kitchen, as observed during an initial tour by a surveyor. The surveyor, assisted by a staff member, found four cartons of fat-free chocolate milk that were expired and confirmed by the staff. Additionally, five unlabeled and undated white paper cups containing ice cream were found in another refrigerator. These findings were confirmed by the staff member, who then discarded the items. The Regional Certified Dietary Manager (CDM) was informed of these findings and acknowledged the issue. She was temporarily covering the position until a new CDM was hired. The surveyor was later provided with documents indicating that the facility would implement an Opening Inspection Report and a Closing Inspection Report to ensure proper food storage practices. The Nursing Home Administrator and the Director of Nursing were made aware of the findings during the exit conference.
Elopement Incident Due to Inadequate Door Security
Penalty
Summary
The facility failed to provide a safe environment to prevent an elopement incident involving a resident identified as being at high risk for wandering. The incident occurred when the resident, who had a history of cognitive impairment and was assessed as a high risk to wander, managed to exit the skilled unit through a door that was not part of the unit and had no lock. The resident was found outside on the facility campus by security after the door alarm had sounded, indicating a breach in the facility's wandering management system. The wandering management system in place, known as Wander Guard, is designed to alert staff when a resident wearing a bracelet approaches a monitored door. However, the system's effectiveness was compromised as the door used by the resident to exit was not equipped with a lock from the inside, allowing the resident to leave the premises. The alarm system did alert staff, but the resident was able to exit the building and was found outside, where they sustained a minor injury. Interviews with staff revealed that the door leading to the Independent Living area locked from the outside but not from the inside, which contributed to the resident's ability to elope. The facility's Director of Nursing confirmed that the double doors of the skilled unit would lock but not alarm if closed, and the door used by the resident was not adequately secured to prevent such incidents. This oversight in the facility's security measures led to the resident's elopement and subsequent fall outside the facility.
Failure to Conduct Quarterly Care Plan Meetings and Update Care Plans
Penalty
Summary
The facility failed to conduct quarterly care plan meetings and to review and revise interdisciplinary care plans accurately for two residents. For one resident, family members reported not being invited to any care plan meetings, and documentation revealed only one meeting in the past year, despite the requirement for quarterly meetings. The Social Service Coordinator confirmed that meetings should be documented in the Electronic Medical Record, but only one sign-in sheet was provided, indicating a lack of consistent documentation and communication with the resident's family. Another resident was readmitted with several diagnoses, including constipation and dysphagia, and was receiving speech therapy and dietary assessments. However, the care plan in the clinical record was outdated, reflecting a previous condition of bilateral lower extremity edema that was no longer present. The Registered Dietitian confirmed the care plan was not updated to reflect the resident's current condition, as the system automatically pulled in old information. This oversight resulted in an inaccurate care plan that did not address the resident's current needs.
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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