Chapel Hill Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Randallstown, Maryland.
- Location
- 4511 Robosson Road, Randallstown, Maryland 21133
- CMS Provider Number
- 215220
- Inspections on file
- 16
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Chapel Hill Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Two residents’ rights were not upheld when one resident’s urinary catheter bag was repeatedly observed uncovered, with the bag cover at one point lying on the floor, and another resident was refused feeding assistance while on the phone with family despite the family’s consent to proceed. The staff member told the resident they would only be fed after ending the call, and leadership later acknowledged the resident had the right to be fed while on the phone but cited staff discomfort as the reason this did not occur.
Surveyors found that the facility failed to develop and implement comprehensive care plans for two residents. One resident used a motorized wheelchair and had a documented safety assessment and an ED note describing a leg injury that occurred while using the device, yet the care plan contained no documentation or interventions related to motorized wheelchair use. Another resident had a documented diagnosis of PTSD and a history of childhood sexual abuse, and while the care plan noted trauma as a focus, it listed no specific interventions to address PTSD or the trauma history.
Surveyors identified that the facility failed to revise person-centered care plans after significant changes in two residents’ conditions. For one resident, the MOLST and paper chart were updated from Full Code to DNR-B with No CPR and palliative/supportive care orders, but the care plan continued to list the resident as Full Code. For another resident who sustained a fall with injuries and was sent to the ER, the existing fall-prevention care plan was not updated to reflect the incident or any new interventions, and no timely review was documented. During interviews, the rehab director reported that therapy provides recommendations after falls but does not revise care plans, and the DON and regional administrator confirmed that no care plan revisions or fall investigation documentation were available.
A resident with dementia and epilepsy fell and suffered a subdural hematoma after a GNA left them unattended with the bed raised, despite a care plan requiring two-person assistance. The facility's inconsistent communication and incomplete staff training on resident assistance levels contributed to the incident.
The facility's dietary staff failed to maintain temperature logs for refrigerators and freezers, did not date or label food items with expiration dates, and handled residents' food without wearing beard covers. These deficiencies were observed during a recertification survey, with the Dietary Manager citing short staffing as a reason for incomplete logs and aides unaware of the beard cover requirement.
The facility failed to provide evidence of annual training on abuse, neglect, and exploitation for all nursing staff. A review of six staff members' records revealed no documentation for 2022 and 2024. The DON confirmed the absence of records for these years, despite providing documentation for 2023.
The facility failed to conduct background checks on certain staff members, including a GNA and an LPN, as revealed during a re-certification survey. The Director of Human Resources could not provide documentation for these checks, and the Administrator was unable to identify or provide files for staff involved in an alleged verbal abuse incident.
A facility failed to promptly report a suspected abuse incident involving a GNA and a resident. The incident, where a GNA placed a wedge pillow on a bed after becoming discouraged, was reported by the resident's family to the ombudsman. The NHA was informed the next day but did not report to OHCQ until the ombudsman raised the issue days later. Both the resident and the GNA denied any abusive intent.
The facility failed to thoroughly investigate incidents involving a resident's injury of unknown origin, an elopement, and an abuse allegation. Inadequate documentation and lack of staff interviews were noted, and training was insufficiently attended. The Nursing Home Administrator confirmed these deficiencies.
A facility failed to accurately code the MDS assessment for a resident's smoking status. The resident was found smoking in their room, but the MDS inaccurately documented no cigarette use. The MDS coordinator confirmed that smoking status should be assessed initially, quarterly, and upon any significant change, but this was not accurately reflected. The NHA validated the inaccuracy in the resident's initial MDS record.
The facility failed to update care plans for two residents, one of whom reported feeling unsafe after an incident, and another who required Ativan for anxiety. Despite investigations and ongoing medication orders, care plans were not revised to reflect these changes, as confirmed by the DON and Activity Director.
A resident with adequate cognitive ability did not receive scheduled showers due to inadequate facility accommodations, resulting in bed baths without documented refusals or encouragement for showers. Staff interviews revealed the lack of appropriate shower facilities for residents unable to sit in a shower chair, and the resident eventually received a shower after surveyor intervention.
A resident on blood-thinner medication underwent a tooth extraction without holding the medication, leading to excessive bleeding and hospital admission. The RN was unaware of the dentist's visit and did not document informing the dentist about the medication intake. The facility ceased using the dentist due to communication issues.
A facility failed to monitor a resident's significant weight changes, resulting in a 20-pound loss over two months without physician notification. The resident, with failure to thrive and swallowing difficulties, required full meal support. Despite documented weight refusals, there was no evidence of further intervention or communication with the physician. Staff interviews revealed inconsistencies in communication and documentation processes, which were validated by the Nursing Home Administrator.
A facility failed to ensure the justified use of psychotropic medication for a resident with anxiety. The resident was prescribed Ativan without implementing or documenting non-pharmacological interventions or behavior monitoring. The facility did not monitor the resident's psychiatric symptoms, and interviews confirmed the lack of non-pharmacological interventions before administering the medication.
The facility failed to ensure GNAs received training on resident safety and care after an alleged abuse incident. One GNA had no records of training on safety and mobility, while another was involved in an incident with a resident but lacked training on customer service and timely reporting. The Nursing Home Administrator confirmed the absence of these training records.
The facility failed to ensure a safe and clean environment in two bathrooms, where floor radiator heaters had missing end caps, exposing sharp, rusted edges. In one bathroom, two unsecured metal pieces were also present, and a paper towel dispenser was missing. The Director of Maintenance acknowledged these issues, but the radiator heater in one bathroom remained uncapped, posing a risk to residents.
The facility failed to notify a resident and their representative in writing about the bed hold policy when the resident was transferred to an acute care facility. During a recertification survey, it was found that there was no written evidence of the policy being communicated. Interviews with the DON and a Social Worker confirmed the lack of documentation.
A facility failed to maintain an effective communication system for a non-English speaking resident who speaks only Russian. Staff interviews revealed reliance on basic sign language and family assistance for communication, with no consistent tools or interventions in place. The care plan noted the language barrier, but lacked specific strategies to address it. The Nursing Home Administrator mentioned tools like a picture board and Google Translate, but their use was not verified.
The facility failed to properly store medications, with two opened insulin vials not discarded within the required 28-day period and expired supplies found in the medication storage room. These issues were identified during a recertification survey and confirmed with the ADON.
The facility failed to prevent infection and protect the dignity of residents with indwelling catheters by improperly using pillowcases for Foley bags. Additionally, a resident did not receive complete TB screening, and an RN did not sanitize hands between medication administrations, breaching infection control protocols.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Maintain Dignity and Respect Resident Communication Rights
Penalty
Summary
The facility failed to promote resident dignity for a resident with an indwelling urinary catheter. On 3/23/2026 at 8:30 AM, a surveyor observed that this resident’s urinary catheter bag was hanging from the bed without a cover. On 3/24/2026 at 12:35 PM, the same resident was observed with a cover over the urinary catheter bag. However, on 3/26/2026 at 2:43 PM, the resident was again observed lying in bed with the urinary catheter bag uncovered, and the bag cover was seen lying on the floor next to where the catheter bag was hanging. These observations showed that the facility did not consistently ensure the catheter bag was covered, which the surveyor identified as a failure to maintain the resident’s dignity. The facility also failed to uphold a resident’s right to self-determination and communication during a mealtime. A facility-reported incident and subsequent interviews revealed that a resident was on the phone with their sister, who was also the resident representative, and their mother at lunchtime when staff arrived to assist with feeding. The staff member told the resident they would be fed after they finished their phone conversation and refused to feed the resident while they remained on the phone, despite the sister stating it was acceptable to feed the resident during the call. The staff member left, stating they would return once the resident was off the phone. During an interview, the DON acknowledged that the resident had the right to be fed while on the phone but stated that staff could not be made to do something they were uncomfortable with. The surveyor informed the DON that the resident’s rights had been denied because the resident had to end the phone call in order to receive their meal.
Failure to Develop Comprehensive Care Plans for Motorized Wheelchair Use and PTSD
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive care plans for two residents. For one resident who used a motorized wheelchair, interviews with the DON, Administrator, and Occupational Therapist confirmed that the resident had a power mobility device and that a safety assessment for its use had been completed by therapy. The resident’s medical record included an Emergency Department physician note documenting the resident’s report that they were in their motorized wheelchair when they sustained a leg skin tear or laceration after running into their bed. The facility’s matrix and records showed the resident had been admitted and later discharged, and a power mobility indoor driving assessment dated several months prior was provided. Despite this information and the confirmed use of a motorized wheelchair, review of the resident’s care plan showed no documentation addressing the resident’s use of a motorized wheelchair. For another resident, record review showed documentation in the facility matrix and in a Quarterly MDS that the resident had a medical diagnosis of post-traumatic stress disorder (PTSD) and a history of trauma related to childhood sexual abuse. The resident’s care plan focus reflected this trauma history; however, the only listed intervention for that focus was the word “trauma,” with no specific interventions identified to address the PTSD diagnosis or trauma history. During an interview, the Nursing Home Administrator was informed that the resident had a PTSD diagnosis, but the surveyor could not locate any detailed interventions in the care plan beyond the generic trauma notation.
Failure to Revise Care Plans After Code Status Change and Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered care plans were timely updated and revised by the interdisciplinary team following significant changes in residents’ status and events. For one resident, a social services note documented that the Maryland MOLST was reviewed and changed from Full Code to DNR-B on a specified date, and the paper chart contained a MOLST form with orders for No CPR, Option B, Palliative and Supportive Care. However, the resident’s care plan still contained a focus stating that the resident’s Full Code MOLST would remain in place through the review date, and this care plan was not revised to reflect the updated code status. During record review with the Nursing Home Administrator, it was confirmed that the MOLST had been updated but the care plan had not been revised accordingly. The deficiency also includes the facility’s failure to revise a resident’s care plan after a fall event. A progress note by an LPN documented that another resident experienced a fall, sustained several injuries, and was transferred to the emergency room. Review of this resident’s care plan showed that no revisions were made to the existing fall interventions in response to the fall, and the care plan was not documented as reviewed and revised until a later date. During interviews, the Director of Rehabilitation stated that therapy makes recommendations and sees residents after falls but does not revise the care plan and was unsure if nursing was responsible for care plan revisions. The DON and Regional Administrator confirmed that no care plan revisions had been made in response to the fall and that there was no recollection or documentation of a fall investigation.
Failure to Provide Adequate Staff Support Leads to Resident Injury
Penalty
Summary
The facility failed to provide the specified number of staff support needed when providing care for residents, resulting in a serious accident. A resident with a history of dementia, epilepsy, and seizure disorder, who was dependent on activities of daily living, fell out of bed and suffered a left acute frontal subdural hematoma requiring surgery. The incident occurred when a Geriatric Nursing Assistant (GNA) left the resident unattended with the bed raised to her waist level, contrary to the care plan that required two-person assistance. The investigation revealed that the GNA admitted to leaving the resident unattended while she went to the bathroom to wet a towel, during which time the resident fell. The facility's investigation also showed that the GNA was aware of the resident's squirming behavior but failed to ensure the resident's safety by not lowering the bed or securing the resident. The care plan clearly indicated the need for two-person assistance, which was not followed, leading to the resident's fall and subsequent injury. Interviews with other staff members indicated inconsistencies in how they were informed about the required assistance levels for residents. Some staff relied on information from the rehabilitation team, while others referred to notes on the resident's bed or electronic health records. The facility's documentation and training records were incomplete, as not all staff received the necessary in-service education on resident safety and transfer mobility, contributing to the deficiency.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The dietary staff at the facility failed to maintain proper temperature logs for the refrigerators and freezers from January 4 to January 6, 2025. During an initial tour of the kitchen, it was observed that the temperature logs were not completed, and the Dietary Manager attributed this to being short-staffed during those days. However, during a follow-up visit, the missing temperature logs were found to be completed, but the Dietary Manager could not provide a reason for this discrepancy. Additionally, the dietary staff did not date or label food items stored in the refrigerator and freezer with expiration dates. Items such as a large bowl of beefaroni meal, tomatoes, carrots, cheese, sour cream, frozen vegetables, and French fries were found without proper labeling. Furthermore, a dietary aide was observed handling residents' food without wearing a beard cover, and during a follow-up visit, two dietary aides were seen without beard covers despite having beards. The aides mentioned that they were unaware of the requirement and that beard covers were being ordered.
Deficiency in Annual Abuse, Neglect, and Exploitation Training
Penalty
Summary
The facility failed to provide evidence that all nursing staff received annual training on abuse, neglect, and exploitation, as required. During a recertification and complaint survey, the surveyor reviewed the training records of six randomly selected nursing staff members, including registered nurses and geriatric nurse aides, and found no documentation of the required training for the years 2022 and 2024. The Director of Nursing stated that the facility offered annual abuse training and provided documentation for 2023, but confirmed the absence of records for the other years. This deficiency was identified for all six staff members whose records were reviewed.
Failure to Conduct Background Checks on Staff
Penalty
Summary
The facility administration failed to ensure that background checks were conducted for certain employees, which is a critical measure to protect residents from abuse, neglect, and theft. During a re-certification survey, it was found that four out of nine employees reviewed did not have documented background checks. Specifically, the Director of Human Resources was unable to provide a background check for GNA #26, despite reviewing both paper and electronic employee records. Additionally, the Administrator could not identify or provide employee files for GNA #46, LPN #47, and GNA #48, whose initials were listed in a facility reported incident for alleged verbal abuse. This lack of documentation and identification indicates a significant oversight in the facility's hiring and record-keeping processes.
Delayed Reporting of Suspected Abuse Incident
Penalty
Summary
The facility staff failed to immediately report an allegation of suspected resident abuse involving a Geriatric Nursing Assistant (GNA) and a resident. The incident allegedly occurred when the GNA was attempting to position a wedge pillow under the resident's feet but became discouraged and placed the wedge on the bed, stating she would return later. The resident did not perceive this action as abusive, nor did the roommate, but the family reported the incident to the ombudsman during a care plan meeting. The Nursing Home Administrator (NHA) was informed of the incident the day after it occurred but did not report it to the Office of Healthcare Quality (OHCQ) until it was brought up by the ombudsman four days later. The NHA conducted interviews with the resident and the GNA, both of whom denied any abusive intent. Despite this, the facility's delay in reporting the incident to the OHCQ was noted as a deficiency during the recertification survey.
Investigation and Documentation Deficiencies in Resident Incidents
Penalty
Summary
The facility failed to thoroughly investigate a resident's injury of unknown origin, as evidenced by the lack of documentation for interviews with other residents. Resident #30 was found with a bruise on the left flank and coccyx, and while the facility conducted staff interviews and hospital follow-ups, they did not interview other residents to verify their safety. The Nursing Home Administrator confirmed the absence of these interviews during a review with the surveyor. Additionally, the facility did not adequately address an elopement incident involving Resident #23, who left the building unnoticed by staff. The investigation lacked an interview with the staff member who initially observed the resident leaving via camera. Although in-service training was provided on the day of the incident, only nine nursing staff members attended, despite the facility having more staff. The Nursing Home Administrator acknowledged these shortcomings. Furthermore, the facility's investigation into an allegation of abuse involving Resident #19 was incomplete, as there was no documentation of witness statements, skin assessments, or abuse training following the incident.
Inaccurate MDS Assessment for Resident's Smoking Status
Penalty
Summary
The facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for a resident reviewed for smoking during the recertification/complaint survey. The investigation revealed that the resident was found smoking in their room, and although an initial smoking assessment was completed upon admission, the MDS assessment inaccurately documented no cigarette use. This discrepancy was identified during a review of the resident's medical records, which showed that the resident was admitted in October 2022, and the incident of smoking occurred in November 2022. The MDS coordinator confirmed that smoking status should be assessed initially, quarterly, and upon any significant change, but this was not accurately reflected in the resident's MDS assessment. The Nursing Home Administrator validated the inaccuracy in the resident's initial MDS record.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility staff failed to revise the interdisciplinary care plans to meet the needs of two residents, leading to deficiencies in care. For one resident, an incident was reported where the resident did not feel safe due to being touched by someone. Despite the facility's investigation, which concluded that the resident was confused about their roommate's gender, the care plan was not updated to reflect this incident. The Director of Nursing confirmed that the care plan should have been revised following the incident, but it was not. For another resident, the care plan did not reflect changes in behavior that required the administration of Ativan for anxiety. The initial order for Ativan was placed and renewed multiple times, but the care plan goals and interventions were not updated to address these behavior changes. Additionally, the activity care plan goals and interventions were not revised to reflect the resident's current needs, as confirmed by the Activity Director and other staff members. This lack of revision in care plans indicates a failure to provide appropriate and individualized care for the residents.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility staff failed to ensure that a dependent resident's personal hygiene needs were adequately met by not providing showers as scheduled. This deficiency was identified during a recertification/complaint survey for a resident who expressed dissatisfaction with not receiving showers. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating adequate cognitive ability, confirmed during an interview that he had not been receiving showers and expressed a desire to have them. The facility's records showed that the resident was scheduled for showers twice a week, but instead, he was given bed baths without documentation of refusal or encouragement to take showers. Interviews with facility staff, including a Geriatric Nurse Aide (GNA) and the Director of Nursing (DON), revealed that the resident had been receiving bed baths due to the facility's shower room not having appropriate accommodations for his condition. The GNA stated that refusals were documented, but there was no record of the resident refusing showers or being encouraged to take them. The DON and Nursing Home Administrator (NHA) acknowledged the lack of appropriate shower accommodations for residents who could not sit in a shower chair, but did not provide a solution. The resident eventually received a shower after the surveyor's inquiry.
Failure to Communicate Medication Concerns Leads to Complications
Penalty
Summary
The facility staff failed to communicate and document a concern regarding a resident's medication regimen prior to a dental procedure, which led to complications. The resident, who was on blood-thinner medication, underwent a tooth extraction without the necessary precaution of holding the medication, resulting in excessive gum bleeding. The electronic health record indicated that the resident had been receiving Eliquis and Aspirin as prescribed, and these medications were administered on the day of the procedure. The Registered Nurse (RN) responsible for administering the medications was unaware of the dentist's visit and did not document informing the dentist about the resident's medication intake. The situation escalated when the resident experienced substantial bleeding post-extraction, necessitating a trip to the emergency department. Despite attempts to manage the bleeding with gauze and communication with the on-call physician, the resident's condition required hospital admission. The Nursing Home Administrator acknowledged the communication issues with the contracted dentist, who did not inform the facility of her visits, leading to the decision to cease using the vendor. The dentist was no longer reachable for further clarification as she no longer worked with the facility.
Failure to Monitor Significant Weight Changes in Resident
Penalty
Summary
The facility failed to adequately monitor a resident's significant weight changes, as evidenced by a 20-pound weight loss over a period from April to June 2024. The resident, who was identified as having failure to thrive, swallowing difficulties, and requiring 100% support with meals, had a documented weight of 187.2 pounds in April 2024, which decreased to 166.5 pounds by June 2024. Despite these significant changes, there was no documentation indicating that a physician was made aware of the resident's weight loss or nutritional status. The dietician noted the resident's refusal to be weighed and the need for encouragement, but there was no evidence of further intervention or communication with the physician regarding the resident's condition. Interviews with facility staff revealed inconsistencies in the communication and documentation processes related to the resident's weight management. The dietician and the Assistant Director of Nursing (ADON) described procedures for handling weight refusals and the importance of notifying the physician, yet these steps were not reflected in the resident's records. Additionally, after the resident's readmission to the facility, there was a lack of documented weights or refusals, and no communication with the provider was recorded. The deficiency was validated by the Nursing Home Administrator upon review of the surveyor's findings.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Use
Penalty
Summary
The facility failed to ensure the necessary and justified use of high-risk psychotropic medication for a resident diagnosed with anxiety. The resident was prescribed Ativan, an anxiolytic medication, on an as-needed basis, with the order being renewed multiple times over a period of months. However, the facility did not implement or document any non-pharmacological interventions prior to administering the medication. Additionally, there was a lack of behavior monitoring documentation to justify the administration of the anxiolytic medication. During the recertification survey, it was found that the facility did not have any tasks ordered for monitoring the resident's psychiatric symptoms, including anxiety. Interviews with the Director of Nursing and the Facility Administrator confirmed that the facility did not monitor the resident's behaviors when receiving anxiolytics and did not perform non-pharmacological interventions before administering psychotropics. This deficiency was evident for one of the two residents reviewed for the utilization of unnecessary medication.
Deficiency in GNA Training on Resident Safety and Abuse Prevention
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received necessary training on resident safety and care, particularly after an alleged abuse incident. This deficiency was identified during a recertification/complaint survey, where it was found that GNA #10, hired in July 2023, had no training records for resident safety and transfer mobility. Despite the Director of Nursing's explanation of the training process, there was no evidence of completed training in these areas for GNA #10. The Nursing Home Administrator confirmed the absence of such training in the employee's records. Additionally, the facility's investigation into a self-reported incident revealed that GNA #37 was involved in an incident where a resident reported being hurt and having a dirty brief placed in their face. Although the facility conducted assessments and interviews, and GNA #37 was removed from the assignment, there was no record of the GNA receiving training on customer service or timely reporting related to the incident. The Nursing Home Administrator confirmed the lack of training records for GNA #37 concerning the incident.
Unsafe and Unclean Bathroom Conditions in Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by the condition of the floor radiator heaters in two of the five bathrooms observed during the recertification survey. In the bathrooms shared by rooms 36/38 and 35/37, the floor radiator heaters were found with significant damage, including missing end caps, which exposed sharp, rusted edges. These conditions posed a potential risk of injury to residents using the bathrooms. Additionally, in the bathroom for rooms 36/38, two unsecured long flat metal pieces were leaning against the wall, and the paper towel dispenser was missing. The Director of Maintenance, identified as Staff #8, was shown these deficiencies during the survey. Staff #8 acknowledged the issues, agreeing that the sharp, rusted edges should not be exposed and that the metal pieces should not be present in the bathroom. Despite some corrective actions being taken, such as the removal of the metal pieces and the installation of a paper towel dispenser, the floor radiator heater in the bathroom for rooms 36/38 remained without a cap, leaving sharp edges exposed. This ongoing issue was observed even after initial corrective measures were implemented, with a resident continuing to use the affected bathroom daily.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify a resident and their representative in writing about the bed hold policy when the resident was transferred to an acute care facility. This deficiency was identified during a recertification survey for a resident who was admitted to the facility and later sent to an acute care facility due to a change in their medical condition. A review of the medical record revealed no written evidence that the resident or their representative received notice of the bed hold policy. The Director of Nursing and the Social Worker were unable to provide documentation that the policy was communicated in writing, as confirmed during their interviews.
Failure to Maintain Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to maintain an effective communication system for a non-English speaking resident, identified as Resident #51, who speaks only Russian. During the recertification survey, it was observed that the resident was unable to communicate effectively with staff, as they primarily spoke English and relied on basic sign language and gestures for communication. Interviews with staff revealed that during business hours, an employee from another department assisted with communication, but during off hours and weekends, the staff had to call the resident's family for assistance. This indicates a lack of a consistent and reliable communication method for the resident. A review of Resident #51's medical records showed that the resident was admitted with Russian as their native language, yet there was no evidence of any intervention or tools in place to assist with communication. The care plan noted the language barrier, but no specific strategies were documented to address it. The Nursing Home Administrator mentioned the use of a picture board and Google Translate, but there was no verification that these tools were effectively utilized by the staff. This deficiency highlights the facility's failure to ensure that the resident's communication needs were adequately met, potentially impacting their ability to perform activities of daily living and receive appropriate care.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly store medications, as evidenced by improper labeling and dating of medication vials and expired supplies. During the recertification survey, two opened resident-specific insulin vials were found in the refrigerator of Units 1 A and B. Vial one and vial two were opened on different dates, but neither was discarded within the 28-day period as required by the facility's medication labeling and storage policy. Additionally, in the medication storage room of Unit 2 A and B, an expired spill kit and three expired condom catheter packs were found. These findings were confirmed during a review with the Assistant Director of Nursing.
Infection Control and Dignity Deficiencies in LTC Facility
Penalty
Summary
The facility failed to prevent infection in residents with indwelling catheters and did not protect their dignity. During an initial tour, it was observed that two residents had their Foley bags placed on the floor inside pillowcases, which is not the appropriate method for handling such medical equipment. The LPNs acknowledged the improper use of pillowcases and removed them, but were unsure of the correct alternative. The Director of Nursing admitted to improvising with pillowcases due to a lack of proper dignity bags, which had been ordered but not yet received. Additionally, the facility did not perform complete Tuberculosis screening for a resident, as evidenced by the absence of documentation for the second step of the PPD skin test. Furthermore, during medication administration, an RN failed to sanitize hands between residents, increasing the risk of contamination. The RN also used a medication container lid to measure medication, which was identified as a breach of infection control principles by the Assistant Director of Nursing. These deficiencies were brought to the attention of the Director of Nursing.
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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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