Adelphi Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Adelphi, Maryland.
- Location
- 1801 Metzerott Road, Adelphi, Maryland 20783
- CMS Provider Number
- 215064
- Inspections on file
- 21
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Adelphi Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two roommates became involved in a verbal dispute over clothing placement that escalated into a physical altercation in which each punched the other, resulting in one resident sustaining facial swelling, a forehead laceration, and documented intracranial bleeding and eye injury. A GNA, alerted by calls for help while passing breakfast trays, found one resident bleeding from the forehead, removed the other resident from the room, and notified nursing staff. An RN Supervisor assessed the injured resident and obtained a history that the roommate had struck the resident in the face after an argument about clothes. Records showed that one of the residents had a prior history of aggressive behavior and a previous fight, and psychiatry notes described this as a second patient‑to‑patient altercation, confirming that the facility failed to protect residents from abuse.
A resident with a history of atrial fibrillation, heart failure, and severe cognitive impairment was admitted with a pacemaker, but the care plan did not include any interventions or monitoring instructions for the device. Although staff were informed of the pacemaker through an order, the care plan lacked specific guidance on its management, as confirmed by interviews with the resident and the DON.
Licensed staff did not have or follow orders to monitor a resident's pacemaker, and the care plan lacked interventions for device monitoring. In a separate case, after a resident with mobility and cognitive issues fell, staff moved the resident without notifying a nurse or obtaining an assessment, contrary to facility policy. Both incidents involved failures to follow established protocols for medical device monitoring and fall management.
The facility did not document a behavioral incident involving a resident with psychiatric diagnoses who became aggressive with staff, nor did it ensure accurate transcription of a medication order, resulting in a medication being recorded for the wrong resident. Staff interviews confirmed that required documentation and verification procedures were not followed.
Surveyors found that several residents did not receive wound and skin care treatments as ordered by a wound NP, including missed or delayed applications of ointments, emollients, and dressings, and incomplete documentation of care. Care plans identified the need for these interventions, but the facility did not consistently implement or record them.
A review of medication records and staff interviews revealed that multiple nurses failed to document the administration of PRN narcotic medications in the MAR, despite signing them out in the controlled substance log book. This discrepancy was identified for several residents, indicating that the facility's policy requiring documentation in both the MAR and controlled substance log was not consistently followed.
Surveyors identified improper storage and labeling of food items, unsanitary conditions in kitchen and nourishment rooms, and incorrect dish handling practices. Observations included unsealed and unlabeled bulk foods, undated opened beverages, debris and insects on kitchen windowsills, and a resident-use ice machine with visible contamination.
Surveyors found that the facility did not provide adequate maintenance services, resulting in stained ceiling tiles, dirty air conditioning units, torn window screens, and patched ceiling holes in several rooms. Widespread peeling paint was also observed in many second-floor rooms and hallways, with staff confirming the issue had persisted for some time. Facility leadership acknowledged the ongoing problems and the lack of a clear timeline for repairs.
A resident assessed to need side rails for bed mobility did not have timely access to them, despite documented family preference and care plan interventions. Delays in obtaining physician orders resulted in the resident being without the required mobility device for several days after both initial assessment and readmission.
A resident with scheduled dialysis orders did not receive a required treatment because both dialysis and facility staff failed to recognize the omission, and the resident was not listed on the dialysis schedule. The missed session was only discovered after a call from the resident's representative, and by then, it was too late to provide the treatment.
Surveyors found that two residents were not provided with information about their right to formulate advance directives, as required. In both cases, documentation was either missing or incorrect, and staff confirmed that there was no evidence the residents had been offered this information.
A resident's medication was incorrectly coded as insulin instead of a hypoglycemic agent on the MDS assessment. Review of the MAR and discussion with the MDS Coordinator confirmed the error in medication classification.
Surveyors identified that two residents did not have accurate or complete care plans reflecting their current medical conditions and needs. One resident with an ileostomy and on hemodialysis was incorrectly documented as incontinent, while another resident's care plan failed to address a new pain complaint and lacked specific details. The DON and NHA confirmed the care plans were not person-centered or complete.
The facility did not consistently invite two residents to participate in their care plan meetings or conduct care plan meetings after each MDS assessment, as required. One cognitively intact resident was not documented as being invited or present at care plan meetings, and another resident had no documented care plan meetings following multiple MDS assessments, with a scheduled meeting not occurring as planned.
A resident who was dependent on staff for ADL care and cognitively intact did not consistently receive showers as ordered in their care plan. Documentation was inconsistent, with some records indicating showers were given, while others showed refusals or lacked explanation for missed showers. The resident reported only receiving bed baths and not being offered showers, and interviews with the NHA confirmed the inconsistency in providing necessary hygiene services.
Two residents with physician orders for continuous oxygen therapy were observed without their oxygen supply during and after transport to dialysis. In both cases, staff failed to ensure the oxygen concentrators accompanied the residents, resulting in periods where the nasal cannula was not connected to supplemental oxygen, despite documented orders and care plans requiring continuous administration.
Staff failed to document the administration of PRN narcotic medications in the MAR for three residents, despite signing out the medications in the controlled substance log. This resulted in multiple undocumented administrations, contrary to facility policy requiring documentation in both records.
Staff did not follow infection prevention protocols for a resident with a PEG tube, including leaving an incorrectly dated water flush bag, unlabeled tube feeding bottles, and failing to remove an old, odorous Xeroform strip from the tube site. The required daily dressing change was not completed as ordered, and the presence of the Xeroform strip was unexplained by staff.
A resident was observed being transported in a recliner chair that did not steer properly and had a faulty reclining mechanism, causing abrupt movements of the head and foot sections. A GNA reported that all similar chairs were in this condition, and a UM confirmed the malfunction.
A resident was found with a mattress that did not fit the bed frame, causing it to hang over the sides and not lay flat. Staff were aware of the issue, but maintenance procedures were unclear and documentation of required bed audits could not be provided. The Director of Maintenance could not confirm the mattress type or origin, and no records of annual bed inspections were available.
Garbage bags were left unattended in a hallway after a GNA placed them outside resident rooms following her rounds. The DON confirmed that this practice was not in accordance with facility policy, as garbage should be taken directly to the dirty utility room.
The facility did not consistently notify residents' legal representatives or responsible parties of changes to the plan of care, as required. In several cases, residents with guardians or responsible parties had changes in care or important notices provided without proper documentation that their representatives were informed or had acknowledged these changes, leading to inconsistencies in records and communication.
Surveyors identified that the facility did not maintain accurate and complete medical records for two residents. One resident's care plan and clinical notes inaccurately documented incontinence status despite a history of ileostomy and hemodialysis. In another case, a resident's complaint of wrist pain led to orders for Tylenol and a STAT X-ray, but the MAR did not show Tylenol administration and the X-ray results were missing from the chart until later requested by the DON.
Surveyors observed bugs in a resident's room, an elevator, and dead insects and debris on kitchen windowsills, indicating a failure to maintain an effective pest control program. Pest management records showed repeated treatments for roaches and fruit flies in resident rooms, but no evidence of preventative measures in new resident locations or adequate kitchen cleanliness.
Failure to Prevent Resident‑to‑Resident Physical Abuse Resulting in Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from abuse, as evidenced by a verified resident‑to‑resident physical altercation that resulted in injuries. On the morning of 01/24/2026, two roommates became involved in a dispute over clothing placement in their shared room. One resident reported that their clothes were initially on a chair by the window, and that the roommate later placed their own clothes in the same location. When the first resident moved their clothes to the foot of the bed and informed the roommate that the clothes at the chair were not theirs, the roommate allegedly began using profanity and then punched the resident in the face, prompting the resident to strike back in self‑defense. Staff accounts and documentation corroborated that a physical altercation occurred between the two residents. A GNA, while passing breakfast trays, heard a resident calling for help, entered the room, and observed one resident sitting on the bed and the other at the edge of the bed with blood on the right forehead area. The GNA reported that the injured resident stated the two had argued and that the roommate hit them in the face. The GNA immediately removed the alleged aggressor from the room and contacted the charge nurse. An RN Supervisor also reported being notified by the GNA, entering the room, and finding the resident with facial swelling and a laceration to the right side of the forehead, with the resident stating that the roommate struck them when they refused to allow the roommate to take their clothes. Clinical records and prior documentation showed that the altercation caused significant injury and that one of the residents had a known history of aggressive behavior. A skin status evaluation completed later that day documented a new laceration to the right side of the forehead and facial swelling for the injured resident. Hospital records indicated the resident was seen after an assault and that a CT scan showed a small amount of blood in the brain from being struck in the head, as well as a small eye scratch. Psychiatry notes for the injured resident referenced follow‑up for a patient‑to‑patient altercation requiring EMS transport, and psychiatry notes for the other resident described evaluation after a second patient‑to‑patient altercation and a documented history of aggressive behavior, including a prior fight and recent initiation of a mood stabilizer. The DON confirmed that the facility’s investigation verified the allegation of a resident‑to‑resident physical altercation based on staff witness statements and both residents’ admissions.
Failure to Address Pacemaker Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan that addressed the monitoring and care of a resident's pacemaker. Despite the resident having a documented medical history of atrial fibrillation, heart failure, and severe cognitive impairment, the care plan did not include any focus area or interventions related to the presence or management of a pacemaker. The resident's admission records and Minimum Data Set assessment confirmed these diagnoses and cognitive status, and the care plan only addressed risks for cardiac complications without specifying the pacemaker. Further review of the resident's order summary revealed an order indicating the presence of a pacemaker, with instructions for staff to be aware of this every shift. However, there were no corresponding interventions or guidance in the care plan for staff on how to monitor the pacemaker for proper functioning. Interviews with the resident and the Director of Nursing confirmed the existence of the pacemaker and the expectation that it should be addressed in the care plan, but this was not done.
Failure to Monitor Pacemaker and Inadequate Response to Resident Fall
Penalty
Summary
Licensed nursing staff failed to obtain and follow orders for monitoring a resident's pacemaker for proper functioning. The resident, who had a history of cardiomyopathy, heart assist device, and congestive heart failure, was admitted with a pacemaker, but the care plan did not include interventions for pacemaker monitoring. The only order present was an informational note about the presence of a pacemaker, with no directive for staff to monitor its function. Interviews confirmed that the resident could not recall the last time their pacemaker was checked, and facility leadership acknowledged that no monitoring was being performed by staff. In a separate incident, staff failed to follow facility policy regarding the management of resident falls. A resident with muscle weakness, difficulty walking, and moderate cognitive impairment fell out of bed. The assigned Geriatric Nursing Assistant (GNA) enlisted the help of a housekeeper to lift the resident back into bed without notifying a licensed nurse or having the resident assessed prior to being moved, as required by policy. The fall was not reported to nursing staff until the following day, after the resident complained of leg pain. Both deficiencies were identified through interviews, record reviews, and policy review, which revealed that staff did not follow established protocols for monitoring medical devices and responding to resident falls. The lack of appropriate orders and failure to report and assess a fall before moving the resident directly contributed to the deficiencies cited.
Failure to Document Behavioral Incident and Medication Order Transcription Error
Penalty
Summary
The facility failed to document a behavioral incident involving a resident with a history of bipolar and delusional disorders. The incident occurred when the resident became agitated, was verbally aggressive, and struck the Human Resources Director, prompting law enforcement involvement. Multiple staff interviews confirmed that the event was not recorded in the resident's medical record, progress notes, or risk management forms, despite facility policy requiring documentation of significant changes in condition and behavioral incidents. The lack of documentation was acknowledged by the Assistant Director of Nursing, Director of Nursing, Unit Manager, and Administrator, all of whom stated that such incidents should be recorded to ensure proper monitoring and follow-up. Additionally, the facility failed to ensure accurate transcription of medication orders for another resident. A nurse transcribed a medication order for tranexamic acid onto a resident's Medication Administration Record (MAR) without verifying that the order was actually prescribed to that resident. The error occurred because the nurse did not check the name on the hospital discharge paperwork, resulting in a one-time dose of medication being recorded for the wrong individual. The Director of Nursing and Administrator confirmed that the transcription error was due to a failure to match the resident's name with the correct medication order from the hospital discharge summary.
Failure to Provide Ordered Skin and Wound Care Treatments
Penalty
Summary
The facility failed to provide treatments and care according to the orders and recommendations of a wound Nurse Practitioner (NP) for multiple residents with skin care needs. In several cases, the prescribed wound care treatments, including cleansing, application of ointments, and use of emollients, were either not performed as frequently as ordered or were not documented as completed. For example, one resident with chronic wounds and severe dryness was supposed to receive wound care twice daily, but records showed it was only done once per day, and there was a delay in initiating recommended emollient therapy. Another resident with multiple scabbed areas and dry, flaky skin was observed without the recommended dressings, and the treatment administration record indicated that while a topical corticosteroid was applied, other aspects of the care plan, such as Vaseline application and leg wrapping, were not documented as completed. Additional residents with dry, cracked, or flaky skin had recommendations for daily emollient use and other preventive measures, but there was no documentation that these treatments were provided as ordered. Throughout the review, the surveyor noted that the care plans for these residents identified their risk for skin breakdown and the need for specific interventions, yet the facility did not consistently implement or document the recommended treatments. Interviews with the Nursing Home Administrator confirmed that the concerns regarding the lack of adherence to the wound NP's recommendations were reviewed during the survey.
Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
Surveyors determined that the facility failed to ensure nursing staff were competent in medication administration, specifically regarding the documentation of PRN narcotic medications. During the recertification survey, a review of records and staff interviews revealed that 21 out of 59 licensed nursing staff did not properly document the administration of PRN narcotic medications in the Medication Administration Record (MAR), despite these medications being signed out in the controlled substance log book. This discrepancy was observed during a review of the controlled substance log book on the first floor medication cart, where PRN narcotic medications were signed out but not recorded in the MAR for several residents. The facility's policy requires that after administering medication, staff must document the administration in the MAR or Treatment Administration Record (TAR) and, if necessary, in the controlled substance sign out record. However, surveyors found that this policy was not consistently followed by the nursing staff. The Director of Nursing confirmed that the expectation is for all administered medications to be documented in the MAR, and a list of staff who failed to do so was provided. The Quality Assurance/Staff Development RN also acknowledged the issue during interviews, noting that medication administration competencies are observed monthly or more frequently if needed, but the documentation lapses persisted among the identified staff.
Deficient Food Storage and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen and nourishment rooms related to improper storage and sanitation of food items and utensils. Specifically, nine large cans of green peas lacked clear delivery and expiration dates, and several bulk food items such as cornstarch, parboiled rice, and orzo pasta were found opened, unsealed, or without labels. Cleaned red cereal bowls were stacked face up, contrary to proper procedure, which could allow water to collect. Additionally, debris, dark spots, and dead insects were found on kitchen windowsills near critical food preparation and storage areas. Further inspection of nourishment rooms revealed the absence of a thermometer in a refrigerator, and several food and beverage items were either undated or had unclear labeling. In the freezer, multiple Styrofoam cups with frozen liquid were also missing date labels. The ice machine used by residents was found to have a black substance on the dispensing flap and rust around the storage bin. These findings indicate failures in maintaining sanitary conditions and proper food storage practices as required by professional standards.
Failure to Maintain Clean and Homelike Environment Due to Maintenance Deficiencies
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents. Observations revealed multiple deficiencies in resident rooms, including stained ceiling tiles, dirty and debris-filled air conditioning units, open windows with torn screens, and patched ceiling holes with surrounding stains. These issues were noted in several specific rooms, and not all were included in the facility's maintenance report. The Maintenance Director acknowledged ongoing problems with building leaks and broken window screens, and the Nursing Home Administrator confirmed that staff are expected to report such maintenance concerns. Additionally, surveyors observed widespread peeling paint in 19 rooms and hallways on the second floor, particularly behind beds and chairs. Staff interviews confirmed that the peeling paint had been an ongoing issue, with multiple requests for repairs submitted. The Maintenance Director recognized that paint debris could pose a health hazard but was unable to provide a timeline for completion of the repainting project. The Administrator agreed that the persistent environmental issues were a concern.
Failure to Provide Timely Access to Mobility Device
Penalty
Summary
Facility staff failed to ensure that a resident assessed to need a mobility device, specifically side rails, had timely access to the device. The resident's care plan, initiated on 1/14/25, documented the family's and guardian's preference for side rails, and a bed side rail tool completed on 1/21/25 confirmed consent for their use as an enabler for mobility. Despite these assessments and documented preferences, there was a delay in obtaining a physician's order for the side rails, with the first order not written until 1/29/25. This order was discontinued shortly after due to the resident's transfer out of the facility on 1/30/25. Upon the resident's readmission, the care plan continued to indicate the need for side rails, but no new order was written until 2/7/25, several days after the resident's return. Observations during this period showed the resident in bed without side rails present, despite the documented need and care plan interventions. The deficiency centers on the facility's failure to promptly provide the mobility device as assessed and care planned, resulting in the resident not having access to the required side rails for an extended period.
Missed Dialysis Treatment Due to Scheduling Oversight
Penalty
Summary
A deficiency was identified when a resident with a provider order for dialysis on Tuesdays, Thursdays, and Saturdays did not receive the required dialysis treatment on one scheduled day. Record review showed no treatment notes for the missed session, and interviews revealed that both dialysis and facility staff failed to recognize the missed treatment. The Dialysis Clinical Manager confirmed the missed session and stated that by the time the issue was discovered, it was too late to provide the treatment, and the dialysis center was subsequently closed due to weather. The Director of Nurses reported that the facility only became aware of the missed treatment after a phone call from the resident's representative, and that the resident was not on the dialysis schedule, which led to staff not realizing the omission. The resident was monitored for symptoms, but no issues were reported as a result of the missed treatment.
Failure to Inform Residents of Right to Formulate Advance Directives
Penalty
Summary
The facility failed to inform residents of their right to formulate advance directives, as evidenced by the review of two residents' records. For one resident, a psychosocial assessment documented that the resident did not have advance directives, but there was no documentation indicating that information about initiating advance directives was offered. For another resident, conflicting documentation was found regarding the presence of advance directives, and it was later clarified by staff that the resident did not have any. In both cases, interviews with facility staff and administration confirmed that there was no documentation to show that these residents were offered information about formulating advance directives. These findings were based on record reviews and staff interviews, which revealed a lack of proper documentation and communication regarding residents' rights to be informed about and to formulate advance directives.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to accurately code a resident's medication on the Minimum Data Set (MDS) assessment. During a review of one resident's medical record, surveyors found that the quarterly MDS indicated the resident received an injection of insulin for one day. However, examination of the Medication Administration Record (MAR) for the same period showed that the resident was administered Trulicity by injection, which is a hypoglycemic agent, not insulin. Upon review with the MDS Coordinator, it was confirmed that Trulicity had been incorrectly coded as insulin on the MDS assessment.
Failure to Develop Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents. For one resident, the medical record showed a history of ileostomy and hemodialysis, with no urine output, following a recent hospital readmission. However, the care plan inaccurately documented the resident as incontinent of bladder and/or bowels due to medication use and impaired mobility. This discrepancy was confirmed by the DON during an interview, acknowledging the care plan did not reflect the resident's actual condition. For another resident, after reporting new pain in the left foot following a treatment, the care plan was found to be incomplete and not resident-centered. The care plan only noted a risk for pain and constipation, without specifying causes or addressing the new complaint. The NHA confirmed during an interview that the care plan lacked completeness and person-centered details.
Failure to Invite Residents and Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents were invited to participate in their care plan meetings and that care plan meetings were conducted after each Minimum Data Set (MDS) assessment, as required. In the case of one resident, who was cognitively intact as indicated by a BIMS score of 15, there was no documentation that the resident was invited to or attended care plan meetings following admission. The only invitation on record was sent to the resident's guardian, and there was no note in the medical record indicating that the resident was invited or declined to attend. The Social Work Coordinator acknowledged that she did not document the resident's invitation or declination, and there was no explanation for the resident's absence from subsequent care plan meetings. For another resident, there was no documentation of care plan meetings being conducted after multiple MDS assessments throughout the year. Although a care plan meeting was scheduled, the resident was not present at the scheduled time, and there was no record of who attended the meeting or if it was conducted. The lack of documentation persisted until a care plan meeting was finally documented at a later date. These findings were confirmed through interviews with facility staff and review of medical records.
Failure to Provide Ordered Showers and Maintain Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a cognitively intact resident, who was dependent on staff for activities of daily living, reported only receiving bed baths and not being offered showers as per their care plan. The resident's medical record included an order for showers twice weekly on specific days and shifts. Documentation reviewed by the surveyor showed inconsistencies: only three showers were documented in the point of care system, while shower sheets indicated refusals on some dates and a lack of explanation for missed showers on others. Additionally, the Treatment Administration Record (TAR) showed showers marked as given on multiple dates, but corresponding shower sheets were missing or indicated refusals, creating discrepancies in the records. Interviews with the resident and the Nursing Home Administrator (NHA) confirmed that the resident was not consistently offered or provided showers as ordered. The lack of consistent and accurate documentation, as well as the resident's own report, demonstrated that necessary services to maintain good personal hygiene were not reliably provided to the dependent resident, resulting in a failure to meet the resident's care needs as outlined in their plan of care.
Failure to Provide Continuous Oxygen Therapy During Resident Transport
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for oxygen administration for two residents who required continuous supplemental oxygen. In one instance, a resident with an order for continuous oxygen at 2 liters per minute via nasal cannula was observed being transported to dialysis without the oxygen concentrator, despite having a nasal cannula in place. The staff member responsible for the transport confirmed that the resident required oxygen and returned later to retrieve the concentrator. The resident's medical record included orders and care plan interventions specifying the need for continuous oxygen and monitoring, as well as documentation of ongoing shortness of breath and a goal to maintain oxygen saturation above 92%. In another case, a resident with a diagnosis of COPD and an order for continuous oxygen at 2 liters per minute via nasal cannula was found in bed with the nasal cannula not connected to any oxygen source. The resident stated that the concentrator had likely been left in dialysis, and a staff member subsequently retrieved and reconnected the device. The facility's policy on respiratory care and oxygen equipment required that oxygen support not be initiated or adjusted without a provider's order and described the need for continuous therapy as ordered. The Nursing Home Administrator acknowledged that residents with continuous oxygen orders should not be taken off oxygen for transport convenience.
Failure to Document PRN Narcotic Administration in MAR
Penalty
Summary
Facility staff failed to appropriately document the administration of PRN (as needed) narcotic medications in the Medication Administration Record (MAR) for three residents who were prescribed controlled substances for pain management. Record reviews revealed that, although staff signed out PRN narcotics in the controlled substance log book, they did not consistently record these administrations in the MAR. For one resident, this discrepancy occurred 30 times in a single month. Interviews with nursing staff confirmed that the facility's expectation is for all administered medications to be documented in the MAR, but staff did not notice discrepancies between the narcotic log and the MAR. Further review of the controlled substance sign out logs and MARs for two additional residents showed similar failures to document PRN narcotic administration in the MAR, despite proper sign-out in the controlled substance log. The facility's medication administration policy requires documentation in both the MAR and the controlled substance log after administration. The DON confirmed that several nurses administered PRN narcotics without documenting them in the MAR, as required by facility policy.
Failure to Maintain Infection Control in Enteral Feeding Tube Care
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. During observation, the resident's tube feeding water flush bag was found hanging with an incorrect date, and two unopened Jevity bottles were left unlabeled on a draw table. Record review confirmed that the resident's orders required tube feeding via pump and daily cleansing and dressing of the PEG tube site with split gauze, which was to be dated each shift. Further bedside observation of a PEG tube site dressing change revealed that there was no split gauze covering the insertion site from the previous day, and an old Xeroform strip, which was not part of the resident's care order, was discovered under the external fixation plate. The Xeroform strip was discolored and emitted an odor, and nursing staff could not explain its presence or duration. The unit manager confirmed that staff had omitted to remove the old Xeroform strip, and both the administrator and infection preventionist acknowledged that these findings did not meet infection prevention standards or the facility's standard of care.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, as evidenced by observations of a resident being transported in a malfunctioning recliner chair on two separate occasions. During both observations, the chair did not steer straight, and the reclining mechanism failed to maintain its position, causing the head and foot of the chair to abruptly move. A Geriatric Nursing Assistant (GNA) was seen struggling with the chair, and when questioned by the Unit Manager (UM), the GNA indicated that all the chairs were in similar condition. The UM acknowledged that the chair was not functioning correctly. These findings were based solely on direct observations and staff interviews.
Failure to Ensure Proper Mattress Fit and Document Bed Inspections
Penalty
Summary
A deficiency was identified when a resident's mattress was observed to be too large for the bed frame, causing the mattress to hang over both sides and preventing it from lying flat. The issue was initially reported by the resident, who used the call light to request assistance after previously notifying staff that the bed was not working. Upon investigation, a Geriatric Nursing Assistant responded and indicated that the nurse was already aware of the problem. The Registered Nurse confirmed that maintenance had been contacted, but also revealed unfamiliarity with the facility's computerized repair request system, relying instead on phone calls to notify maintenance. Further inspection by maintenance staff confirmed that the mattress did not fit the bed frame. The Director of Maintenance was unable to identify the origin of the mattress and stated that it was not appropriate for either regular or bariatric beds used in the facility. When asked about regular annual inspections of beds, the Director referenced a computer system for scheduling preventive maintenance but could not provide documentation of completed bed audits. The Nursing Home Administrator also could not produce records of bed audits performed, and no documentation was provided to the surveyor by the time of exit.
Improper Disposal of Garbage in Hallway
Penalty
Summary
The facility failed to maintain a sanitary environment in the common hallway of the East Wing. During an early morning observation, three garbage bags full of waste were found left in the hallway with no staff present. A Geriatric Nursing Assistant (GNA) was observed exiting a resident's room with a garbage bag and explained that she placed garbage outside the door after completing her rounds. Shortly after, two staff members collected the garbage bags and took them to the dirty utility room. The Director of Nursing (DON) confirmed during an interview that garbage should not be left outside resident rooms and should be taken directly to the dirty utility room when emptied.
Failure to Notify Resident Representatives of Care Plan Changes
Penalty
Summary
The facility failed to properly notify residents' legal representatives or responsible parties of changes to the residents' plans of care, as required. In one case, a resident with a court-appointed guardian was given Medicare non-coverage and liability notices without documented notification or acknowledgment from the guardian, despite the guardian being the legal decision-maker. The social services staff stated they had contacted the guardian, but there was no documentation to confirm the guardian was aware of or had acknowledged the notices. In another instance, a resident who was determined unable to make decisions and had a temporary guardian had documentation inconsistencies regarding who was acting as the responsible party. Some records indicated the resident was his or her own decision-maker, while others referenced the guardian, and there was a lack of clarity and documentation about who was notified of care plan changes. A third resident with established guardianship had inconsistent documentation about whether the responsible party was informed of changes to the plan of care, with some notes indicating communication with family members and others lacking evidence that the legal representative was updated.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, resulting in documentation that did not align with accepted professional standards. For one resident who was readmitted after a hospital stay and had a history of ileostomy and hemodialysis, the care plan and multiple clinical notes inaccurately described the resident as incontinent of urine and stool, despite the resident no longer producing urine. The Director of Nursing confirmed these inaccuracies during an interview, acknowledging that the documentation regarding incontinence was not correct. In another case, a resident admitted for rehabilitation and colostomy care reported right wrist pain to an LPN, who documented the complaint, obtained a physician's order for Tylenol and a STAT X-ray, and noted that Tylenol was administered. However, the medication administration record did not reflect any Tylenol given for the relevant period, and the X-ray results were not present in the resident's medical chart at the time of review. The Director of Nursing later confirmed that the X-ray results were not in the chart and had to be requested from the imaging facility, and also confirmed the lack of documentation for the administered medication.
Deficient Pest Control Program and Insect Activity Observed
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of insect activity in resident rooms, common areas, and the kitchen. During an interview with a resident who reported feeling things crawling on them, surveyors observed bugs crawling on the floor and wall of the resident's room. Pest management records showed that the room had been treated for roaches and general insects, and that another room had a history of fruit flies and roaches, with recommendations for additional interventions that were not documented as completed. After the resident was transferred to a new room, there was no evidence of preventative pest control measures or evaluation in the new location, where bugs were also observed. Additionally, a bug was observed by surveyors in an elevator, and the DON confirmed the presence of the insect, which was similar to those seen in the resident's room. During a kitchen tour, surveyors and the kitchen manager observed debris, dark spots, and dead insects on multiple kitchen windowsills near food preparation and storage areas. The kitchen manager confirmed the need for cleaning, and the NHA stated that housekeeping was responsible for monthly cleaning of the kitchen, but evidence of pest presence and debris was still found during the survey.
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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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