Tuckerman Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in North Bethesda, Maryland.
- Location
- 5550 Tuckerman Lane, North Bethesda, Maryland 20852
- CMS Provider Number
- 215320
- Inspections on file
- 15
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Tuckerman Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Two residents were discharged without appropriate reasons or proper documentation. One resident with terminal cancer was told hospice care could not be provided at the facility, despite the admission contract stating otherwise, and the family was not informed of service limitations. Another resident with advanced dementia was discharged due to poor rehab participation and the need for a memory care unit, but there was no documentation that the facility could not meet their needs. In both cases, regulatory requirements for discharge were not met, and staff interviews confirmed discharges were based on therapy participation rather than regulatory criteria.
The facility did not provide the required 30-day written discharge notices to two residents who were being discharged, instead issuing only a Notice of Medicare Non-Coverage (NOMNC). In both cases, the discharges were initiated by the facility due to changes in care needs, and interviews confirmed that neither resident nor their representatives received the mandated 30-day notice explaining the reason for discharge.
A resident's representative requested that the resident remain in the facility to receive hospice care, but staff informed the representative that hospice could not be provided on-site and proceeded with discharge plans. Despite the facility having a contract with a hospice provider and being capable of providing hospice services, staff preferred to discharge residents needing hospice or LTC. The representative appealed the discharge and attempted to find alternative placement, but ultimately felt pressured to take the resident home.
A resident was administered quetiapine and PRN lorazepam for behavioral symptoms without proper documentation of behavior monitoring, nonpharmacological interventions, or attempts at gradual dose reduction. The PRN psychotropic order lacked a required 14-day stop date, and the consent for psychotropic use was signed on admission without evidence of exhausted nonpharmacological approaches. Staff interviews confirmed inadequate documentation and inappropriate diagnoses for medication use.
A resident with advanced cancer diagnoses and in need of end-of-life care was admitted for rehabilitation, but neither the resident nor their representative was informed in writing that the facility did not provide hospice or LTC services. The facility's admission materials did not disclose these limitations, and the family was only verbally notified when discharge planning for hospice was initiated.
The facility did not complete thorough investigations into two separate abuse allegations, as required. In both cases, the DON confirmed that neither staff nor resident interviews or statements were obtained or documented as part of the investigation.
Inappropriate Discharge and Inadequate Documentation for Two Residents
Penalty
Summary
The facility discharged two residents without appropriate reasons and failed to properly document the discharges, as required by regulation. For one resident with metastatic skin cancer and multiple comorbidities, the facility issued a Notice of Medicare Non-Coverage (NOMNC) and informed the family that hospice care could not be provided at the facility, despite the admission contract stating hospice care was available. The family was not informed of any service limitations at admission and expressed concerns about the discharge, especially since the resident’s spouse had dementia and could not provide adequate care at home. The facility staff, including the Social Services Director (SSD) and Director of Nursing (DON), stated the resident was being discharged due to the need for hospice care, but there was no documentation that the resident met any regulatory criteria for facility-initiated discharge. The facility also failed to provide documentation supporting their claim that the discharge was family-initiated. For the second resident, who had advanced dementia and severe cognitive impairment, the facility issued a NOMNC and planned for discharge due to poor participation in rehabilitation and the need for a memory care unit. The attending physician noted the resident was not a good candidate for the facility’s short-term rehabilitation program, but there was no documentation that the facility was unable to meet the resident’s needs or that the resident met the regulatory requirements for discharge. The family was not made aware of any limitations in the facility’s services and struggled to find an appropriate placement due to a pending Medicaid application. Interviews with facility staff confirmed that discharges were often initiated when residents plateaued in therapy or were no longer participating, regardless of whether regulatory discharge criteria were met. The facility’s admission contract and agreements with hospice providers indicated that hospice care could be provided, contradicting staff statements to families. The lack of proper documentation and failure to meet regulatory requirements for discharge were confirmed by the Nursing Home Administrator and DON during the survey.
Failure to Provide Required 30-Day Discharge Notices
Penalty
Summary
The facility failed to provide a required 30-day written notice of discharge to two residents who were being discharged from the facility. In the first case, the Social Services Director (SSD) attempted to issue a Notice of Medicare Non-Coverage (NOMNC) to the resident's family, indicating the end of Medicare Part A coverage and a planned discharge date. However, the family declined to sign the NOMNC, and the SSD explained that the facility could not provide hospice care. Despite this, there was no documentation that a 30-day written discharge notice, including the reason for discharge, was provided to the resident or their representative. The resident's representative confirmed that they did not receive such notice and only received the NOMNC, which was confusing as the resident still had Medicare days remaining. The SSD and DON both confirmed that the discharge was initiated by the facility due to the need for hospice care, not by the family, and that the required 30-day notice was not issued. In the second case, the SSD documented issuing a NOMNC to the family of another resident, with services ending shortly thereafter and a discharge to the community planned. The family appealed the NOMNC, but there was no evidence in the medical record that a 30-day discharge notice was provided to the resident's representative. Interviews with the NHA, DON, and SSD confirmed that the resident was discharged because it was determined they would benefit from a memory care unit, and that only the NOMNC was issued, not the required 30-day discharge notice. These findings were reviewed with facility leadership.
Failure to Honor Resident Representative's Request for Hospice Care
Penalty
Summary
The facility failed to honor the wishes of a resident's representative by not allowing the resident to remain at the facility while receiving hospice services. The resident's representative was informed by the Social Services Director (SSD) that the facility would discharge the resident because they could not provide hospice care on-site, despite the representative's request for the resident to stay and receive hospice care. The representative appealed the discharge twice and attempted to find another facility, but was denied due to the resident's wound care needs. Ultimately, the representative felt pressured by staff to take the resident home. Medical record review showed that the SSD attempted to issue a Notice of Medicare Non-Coverage (NOMNC), but the family did not sign it, and the SSD reiterated that hospice care could not be provided at the facility. A review of the facility's contract with a hospice provider revealed that the facility did have an agreement in place to provide hospice services to residents. Interviews with the SSD, DON, and Nursing Home Administrator confirmed that the facility preferred to discharge residents who required hospice or long-term care, even though they were capable of providing hospice services. The DON and NHA both stated that residents were discharged when they needed hospice care, and the NHA confirmed that the facility would only provide hospice care for a few days before discharging the resident to another setting. The facility was dually certified for rehabilitation and long-term care, but did not honor the resident representative's request for continued care with hospice services.
Failure to Prevent Unnecessary Psychotropic Medication Use and Chemical Restraints
Penalty
Summary
Facility staff failed to ensure that residents were free from unnecessary psychotropic medications and chemical restraints, as well as to limit PRN psychotropic medications to 14 days. For one resident reviewed for discharge, the medical record showed ongoing administration of quetiapine for sundowning and lorazepam as needed for anxiety, with both medications continued for several months. The informed consent for psychotropic use was signed on the day of admission, stating that all nonpharmacological interventions had been exhausted, but there was no evidence that such interventions were attempted or documented prior to medication administration. Physician orders for the resident included lorazepam PRN without a 14-day stop date and quetiapine with an increased dosage for a diagnosis that was not appropriate. There was no documentation of behavior monitoring or attempts at gradual dose reduction for these medications. The psychiatric NP documented continued use of quetiapine for behavior modification, but behavior notes did not reflect monitoring of the targeted behaviors. The medication administration record showed multiple administrations of lorazepam by the same RN, with no documentation of the reasons for administration or nonpharmacological interventions attempted beforehand. Interviews with facility staff, including the attending physician, RN, and DON, confirmed that documentation was lacking regarding the behaviors leading to medication use and the use of nonpharmacological interventions. The DON acknowledged that the consent form was not appropriate and that behavior monitoring and documentation were not adequately performed. The staff also recognized that the PRN order for lorazepam should have included a 14-day stop date, and that the diagnosis for quetiapine was not appropriate.
Failure to Disclose Service Limitations for Hospice and Long-Term Care
Penalty
Summary
The facility failed to inform residents and their representatives about limitations in the care services provided, specifically regarding the inability to provide hospice or long-term care. A review of the admission packet signed by a resident showed that hospice services were listed as provided, and there was no indication of any service limitations. The facility's documentation did not state that residents would be discharged if they required hospice or long-term care, nor did it clarify that only rehabilitation services were offered. Interviews revealed that the resident's representative was not informed at admission about these limitations and only learned of them when the facility initiated discharge planning after the resident's condition declined and hospice care was needed. The resident in question had multiple serious diagnoses, including metastatic cancers and was considered to be at end-of-life shortly after admission. Despite this, the facility proceeded with discharge planning for hospice care, informing the family that the resident could not remain at the facility for hospice services. The Social Services Director and Nursing Home Administrator confirmed that residents needing hospice or LTC were assisted in finding new placement, but this was not documented in the admission materials and was only communicated verbally. The attending physician also confirmed that such residents were transferred elsewhere, further evidencing the lack of written disclosure to residents and their representatives.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse for two residents. In the first case, the facility's investigation into an abuse allegation did not include interviews with staff or the collection of staff statements. The Director of Nursing (DON) confirmed during an interview that these steps were not completed and was unable to locate any staff interviews or statements related to the incident. In the second case, the investigation into another abuse allegation similarly lacked interviews with both residents and staff, as well as the collection of their statements. The DON again confirmed the absence of these critical investigative components and was unable to provide any documentation of interviews or statements when requested by the surveyor.
Latest citations in Maryland
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
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