Caroline Nursing And Rehab

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined that the facility failed to ensure the discharge of

a resident was documented in the medical record that included the resident's status at the time of discharge and the reason for the discharge. This was identified for 1 (Resident #12) of 3 residents reviewed for discharge during the complaint survey.The findings include:On 10/27/2025 at 12:30 PM a review of Resident #12's medical record revealed: A Transfer/Discharge Report that include Resident #12's information of an admission date of 11/11/2023 and a discharge date of 09/23/2025 for transfer/discharge to an acute care hospital. However, further review of Resident #12's medical record revealed no indication of Resident's status or the reason for the transfer/discharge to the hospital. On 10/27/2025 at 1:25 PM

during an interview, Staff #4 Registered Nurse (RN) stated if a resident had a change in condition, an assessment would be completed. An EInteract Change in Condition form is completed, the physician is notified, and all actions are documented in the progress notes of the Electronic medical record.On 10/28/2025 at 8:35 AM during an interview, the Director of Nursing (DON) stated that when a resident is transferred to the hospital, the nurse completes an EInteract form, and a physician order would be obtained.On 10/28/2025 at 12:26 PM the DON verified there was no documentation or Physician order for Resident #12's change in condition that resulted in him/her being transferred to the hospital on [DATE REDACTED]. At

this time the DON was made aware of the concern.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Caroline Nursing and Rehab

520 Kerr Avenue Denton, MD 21629

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

September indicated that nurse's notes were documented for the Fish Oil as medication unavailable. There was no evidence that indicated Pharmacy, or a Physician was notified about the unavailable medication.

On 10/27/2025 at 1:20 PM during an interview, Staff #3 Certified Medication Aide (CMA) stated that if a medication is unavailable, she documents in the electronic medical record the medication is unavailable and informs the nurse.

On 10/27/2025 at 1:25 PM during an interview, Staff # 4 Registered Nurse (RN) stated if a medication is unavailable, the Pharmacy must be contacted to ascertain the medication's delivery status. The Physician should be notified for an alternative medication, and the Omnicell (a backup system for nurses to retrieve medication) should be checked. Notification to both the Physician and Pharmacy is required on the first day of the medication's unavailability.

On 10/28/2025 at 8:35 AM, during an interview with the Director of Nursing (DON) stated that if a medication is unavailable, the pharmacy would be contacted for a refill, or the backup system would be used to obtain the medication. Nurses would contact the Physician if a medication were on backorder. The Director of Nursing (DON) was informed of concerns at this time.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Caroline Nursing and Rehab

520 Kerr Avenue Denton, MD 21629

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

period was 2 or 3 hours but acknowledged he should have placed the order in the Electronic medical record. He documented the blood sugar monitoring in the vital signs section of the electronic medical record. He confirmed that blood sugars were not being monitored every 15 minutes following the insulin medication error.

On 10/28/2025 at 8:45 AM during an interview, the Director of Nursing stated that if a physician ordered blood sugar monitoring every 15 minutes, such an order should be documented in the medical record 2) On 08/26/2025 at 11:56 AM a progress note for Resident #13 indicated that Insulin Glargine (a long-acting insulin), 10 units once daily, was held due to low morning glucose. However, a review of Resident #13's medical records showed no evidence of physician notification or Physician order to hold the Insulin Glargine for low blood sugar.

On 10/28/2025 at 8:45 AM during an interview, the Director of Nursing indicated that if a nurse were to withhold scheduled insulin, he would expect a physician's order and notification to the physician. 3) A portion of the investigation for complaint #2575219, conducted on 10/27/25 at 10:12 AM, revealed that Resident #4 had a prescribed medication for pain, Oxycodone 15mg every 8 hours, from 7/18/25 to 7/28/25. The order was changed to Oxycodone 5mg every 6 hours as needed, starting on 7/29/25.

On 10/27/25 around 10:30 AM, a review of the Medication Administration Record (MAR) for Resident #4 for July 2025 revealed that Oxycodone 5mg was administered on 7/29/25 at 00:37 AM and 07:15 AM.

However, a further review of Resident #4's controlled drug record for Oxycodone 15mg showed that the resident was dispensed the Oxycodone 15mg tablet on 7/29/25 at 00:37 AM and 7:15 AM. There was no additional controlled drug sheet for the Oxycodone 5mg dose that was ordered.

During an interview with the Director of Nursing (DON) on 10/27/25 at 12:21 PM, the surveyor reviewed Resident #4's medical record with the DON. The DON verified that Resident #4 did not have medical records supporting the administration of Oxycodone 5mg. He confirmed that, per the medical records, Resident #4 received Oxycodone 15mg on 7/29/25 instead of the ordered 5mg of Oxycodone. The surveyor shared concern with the DON that Resident #4 received the wrong dose of Oxycodone on 7/29/25.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/29/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Caroline Nursing and Rehab

520 Kerr Avenue Denton, MD 21629

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on the investigation of complaints, record review, and staff interviews, it was determined that the facility staff failed to document the administration of medication in a resident's Medication Administration

Record (MAR). This was evident for one (Resident #4) of the four residents reviewed for medication administration during the complaint survey.The findings include:A portion of the investigation for complaint #2575219, conducted on 10/27/25 at 10:12 AM, revealed that Resident #4 received Narcan (naloxone), a life-saving drug that can reverse an opioid overdose, on 7/29/25 due to a lethargic condition.A further

review of Resident #4's progress note revealed that Staff #19 (Registered Nurse) documented on 7/29/25 at 1 PM: This nurse has made the clinical decision to Narcan resident once. However, there was no documentation for the medication in the MAR.During an interview with Staff #1 (Registered Nurse) on 10/27/25 at 1:03 PM, she stated that a resident who received Narcan should be documented in both the MAR and the progress note.In an interview with the Director of Nursing (DON) on 10/29/25 around 1 PM,

the surveyor shared the concern that the facility staff did not document Resident #4's Narcan administration. The DON validated the concern.

Event ID:

Facility ID:

If continuation sheet