Denton Nursing And Rehab

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and medical record review, it was determined the facility failed to ensure that the resident's call light was within reach, per the individualized care plans, to allow access to assistance when needed. This was evident for 1 (#13) of 14 residents reviewed during a complaint survey. The findings include: On 9/3/25 at 10:00 AM observation was made of Resident (R) #13 lying in bed. R #13 asked the surveyor to hand him/her the hair brush that was on the night stand. At that time observation was made of

the call bell lying on the floor in front of the oxygen concentrator. R #13 was asked how he/she called the nurse. R #13 stated that the call bell was usually on the top of the bed, but [name] took it away from him/her because he/she was ringing it too much. At that time the surveyor showed Certified Medicine Aide (CMA) #23 the call bell that was lying on the floor. CMA #23 placed the call bell on the bed.Review of R #13's medical record revealed an ADL (activities of daily living) care plan related to hemiplegia (paralysis or weakness on one side of the body) that was initiated on 10/21/24. The intervention on the care plan stated, encourage the resident to use bell to call for assistance.A second care plan, at risk for falls had the intervention, be sure the resident's call light is within reach on [his/her] right side and encourage the resident to use it for assistance.On 9/3/25 at 10:55 AM the acting Director of Nursing (DON) and Assistant DON were informed of the observation. They stated that they were made aware and they were investigating

the incident.

Residents Affected - Few

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Review of Staff #34's employee file revealed Staff #34 was a LPN (licensed practical nurse) and on 12/10/24 Staff #34 was terminated with the reason documented due to on 11/28 several staff members reported issues with Resident (#12) immediate action was not taken.

Interview with the Assistant Director of Nursing on 9/3/25 at 10:45 AM confirmed Staff #34 did not notify Resident #12's physician timely on 11/28/24 when the Resident had a change in condition. 2.On 8/28/25 at 11:50 AM a review of complaint 295977 alleged there was no communication with the RP when there were medication changes.

On 8/28/25 at 11:50 AM a review of Resident (R) #16's medical record was conducted. R #16 was admitted to the facility in August 2023 with diagnoses that included but were not limited to non-rheumatic aortic (valve) stenosis, hyperlipidemia, dementia, hypertension, atrial fibrillation, and heart disease.

Review of physician's orders revealed on 3/6/25 the anti-psychotic medication Risperdal was changed from 0.25 mg every day to twice per day. There was no RP notification found in the medical record.

On 3/19/25 there was a new order for the anti-anxiety medication Buspar 5 mg. twice per day. There was no RP notification found in the medical record.

On 4/16/25 the Risperdal dose increased to 0.5 mg twice per day. There was no RP notification found in the medical record.

On 4/25/25 the Buspar frequency was increased from twice per day to three times per day. There was no RP notification found in the medical record.

On 4/30/25 the Risperdal does was increased to 0.75 mg. twice per day. There was no RP notification found

in the medical record.

On 9/4/25 at 9:48 AM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she thought it was an issue before she started working at the facility but was not currently an issue. The ADON reviewed the medical record and confirmed there was no documentation related to RP notification.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on review of facility reported incidents, record review, and interview, it was determined the facility failed to report an injury of unknown origin within 2 hours of becoming aware of the injury, to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (#1) 9 residents reviewed for 10 facility reported incidents during a complaint survey. The findings include: On 8/28/25 at 7:53 AM a review of facility reported incident 295995 was conducted and revealed on 4/6/25 at 5:38 PM a staff nurse was made aware of Resident #1 having a swollen, bruised left eye. Review of the facility's investigation revealed

the resident had severe cognitive impairment and was unable to say what happened to his/her eye. Review of the email confirmation revealed the initial self-report was sent to OHCQ on 4/7/25 at 7:57 AM, which was not within 2 hours of being informed of a bruised and swollen eye that Resident #1 obtained while residing

on the Memory Care Unit.On 9/3/25 at 10:55 AM an interview was conducted with the interim Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON and ADON confirmed the findings as it was initially unknown if the resident was hit, fell, or had some other mechanism of injury.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility reported incidents, documents, and staff interview, it was determined the facility failed to provide documentation that allegations of misappropriation of property were thoroughly investigated. This was evident for 1 (#2) of 9 residents reviewed for facility reported incidents during a complaint survey. The findings include: On 9/2/25 at 11:52 AM a review of facility reported incident 295797 was conducted and revealed Resident #2 alleged that on 12/17/24 between 10:00 AM and 1:00 PM someone entered the resident's room and stole money, a gift card, and 10 gift certificates. Review of the facility's investigation revealed written statements from (3) geriatric nursing assistants (GNA), (1) from the previous Director of Nursing (DON), and (3) other staff in leadership positions. The facility failed to obtain interviews or statements from any of the nurses that were working, staff from previous shifts, housekeeping staff, maintenance staff, or dietary staff that would have had access to the resident's room. On 9/4/25 at 11:08 AM an interview was conducted with the Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON). They both confirmed that other staff should have been interviewed in the investigation process.

Residents Affected - Few

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on medical record review and interview, it was determined that the facility staff failed to have quarterly care plan meetings for residents (Resident #9). This was evident for 1 of 14 residents reviewed

during a complaint survey. The findings include:Once the facility staff completes an in-depth assessment (MDS) of a resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each assessment time of the resident to ensure the interventions on the care plan are accurate and appropriate for the resident. Care plan meetings are held each quarter and as needed. Review of Resident #9's medical record on 8/27/25 revealed the Resident was admitted to the facility in November

1. 2022. Further review of Resident #9's medical record revealed the last quarterly care plan meeting was in

December 2024. The facility staff completed quarterly MDS assessments on 3/17/25 and 6/17/25. The facility staff failed to have a quarterly care plan meeting in March and June 2025. Interview with Social Services Assistant on 9/3/25 at 12:25 PM confirmed there is no evidence the facility staff had a quarterly care plan meeting in March and June 2025. Interview with Resident #9 on 9/3/25 at 1:35 PM, Resident #9 stated he/she had not had any care plan meetings this year and has been asking for them. Interview with

the Assistant Director of Nursing on 9/3/25 at 2:30 PM confirmed the facility staff failed to have a quarterly care plan meeting for Resident #9 in March and June 2025.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 0689 Level of Harm - Actual harm Residents Affected - Few

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

initiated on 1/25/24, had the intervention, the resident requires Hoyer Lift with 2 staff assistance for transfers with a date initiated of 4/30/24.Review of the actual nursing schedule for 12/16/24 documented that there was 1 nurse (LPN #15) and 2 GNAs (GNA #16, and another GNA) for the 300 unit, the unit where R #11 resided. It was noted that GNA #16 was assigned to unit 300 and unit 400, therefore GNA #16 had a split assignment.On 8/28/25 at 8:10 AM an interview was conducted with LPN #15 who stated, I remember them coming to get me that [he/she] fell out of the Hoyer lift. I called the doctor and 911 and had [him/her] sent to the hospital. LPN #15 stated that they told her GNA #16 was transferring the resident by herself. I think we were short staffed that day. We worked short a lot. It happened at the end of day shift. I thought it was a lot taking care of people for the GNAs when short staffed. When I went in there the resident was on the floor. I can't remember if [he/she] was in pain. It was so busy, crazy that day and I was

the only nurse on those 2 hallways.On 8/28/25 at 9:25 AM an interview was conducted with Staff #17, the previous Director of Nursing (DON). Staff #17 stated, one of our aides was transferring [him/her] by herself without a second person and she said the leg hit the bed and the resident slid out of the sling and fell on

the floor. It was the right size sling. It was [his/her] sling. Staff #17 stated, We let her (GNA #16) go for transferring without a second person that resulted in the resident being hurt. On 9/2/25 at 3:02 PM GNA #22 was interviewed and stated that Resident #11 was totally dependent on staff for all ADLs. GNA #2 stated that Resident #11 was transferred with a Hoyer lift. I was working the morning shift. It happened at

the end of the shift, and I was actually leaving. I was at the desk charting. I did hear a yell and then I went down to see what happened and I went and got the nurse. GNA #2 stated, the aide that was taking care of

the resident at the time was in the room. When I went in there she was the only one in there when I walked in. All she said was that she was transferring [him/her] back into the bed and it was a split body sling, and [he/she] had fallen through it. I was on the 300 hallway. The groups on that hall changed a lot and I did not have [him/her.] We must have had a split hallway. Sometimes if we are short we have a split hallway. We did work short last December. On day shift I usually take care of 11 or 12 residents. That day we only had 3 aides on day shift. That is about 15 to 16 people that we would have had to take care of. That is a lot for day shift because most of them are total care. I can say sometimes I have transferred people by myself, but

after that incident I have not transferred by myself using the Hoyer lift. During that time the nurse would try her best to help with transfers or a unit manager or someone but if they were too busy I'd have to do it myself, especially if it were 3 of us having 15-16 residents a piece. Prior to the fall I would see other GNAs transferring with the Hoyer by themselves. When I went in the room the resident was lying flat on [his/her] back. [He/She] was saying that [he/she] was in pain. I don't recall if [he/she] was crying but I do remember [him/her] saying [he/she] was in a lot of pain. There was a wound on [his/her] bottom and I believe it was bleeding after the fall. We got [him/her] back in bed with the Hoyer. It was 4 of us that got [him/her] back in bed. [He/She] was saying [he/she] was in pain when we were putting [him/her] back to bed. On 9/3/25 at 9:00 AM an interview was conducted with Physician #31. He stated he remembered the incident and stated, it was a big deal. Why was one person transferring the resident?On 9/4/25 at 11:30 AM the Nursing Home Administrator (NHA) and the interim DON were informed of the concern.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician ordered blood pressure and heart rate parameters for administering a blood pressure medication. This was evident for 1 (#6) of 13 residents reviewed during a complaint survey. The findings include: On 8/28/25 at 11:50 AM a review of Resident (R) #6's medical record was conducted. R #6 was admitted to the facility in August 2023 with diagnoses that included but were not limited to non-rheumatic aortic (valve) stenosis, hyperlipidemia, dementia, hypertension, atrial fibrillation, and heart disease. Review of R #6's physician's orders revealed the order for Metoprolol Tartrate 100 mg. two times per day related to hypertension (high blood pressure) and atrial fibrillation. Atrial fibrillation (AFib) is a heart rhythm disorder where the upper chambers of the heart (atria) beat irregularly and rapidly. The physician's order stated to hold for b/p (blood pressure) less than 110/65 and HR (heart rate) less than 65.Review of R #6's May 2025 Medication Administration Record (MAR) documented on 5/15/25 in the PM that the HR was 60. The medication was given. On 5/30/25 in the AM the b/p was 105/71 and the medication was given. Review of R #6's June 2025 MAR documented on 6/16/25 in

the AM the HR was 62, 6/17/25 in AM the b/p was 109/64, and on 6/27/25 in the AM the HR was 59. The medication was given each time.Review of R #6's July 2025 MAR documented on 7/14/25 in the PM the HR was 62. The medication was given. Review of R #6's August 2025 MAR documented on 8/12/25 in the AM the HR was 61, on 8/13/25 in the AM the HR was 62, and on 8/23/25 in the PM the HR was 62. The medication was given. Review of R #6's September 2025 MAR documented on 9/2/25 in the AM the HR was 60. The medication was given. On 9/4/25 at 8:12 AM an interview was conducted with Staff #30. The surveyor reviewed the physician's order with her for the Metoprolol. Staff #30 stated that she would hold if one or the other was below parameters, either the blood pressure or heart rate. When the surveyor read the order to her with the word and she said, it should be or. Staff #30 stated, if there is a question about whether to hold or not hold the medication, I would call the physician.On 9/4/25 at 8:18 AM an interview was conducted with Physician #31. The surveyor read the order to him and asked if staff should hold only if both the b/p and the HR were outside of parameters as the order read. Physician #31 stated, no, if the HR is below 65 the med should be held or if the b/p was below 110/65 the med should be held. Physician #31 agreed that the order should have read OR so he changed it at that time. Physician #31 was informed of

the times when the medication was given when it was outside of the physician ordered parameters.

Physician #31 stated he would expect a phone call if there was a question about whether to hold or give the medication.On 9/4/25 at 9:33 AM the issue was discussed with the Assistant Director of Nursing (ADON), Nursing Home Administrator (NHA) and Staff #32. They all agreed the order should have said OR and not and. They were informed of the days that the medication was given when outside of physician ordered parameters.

Residents Affected - Few

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #5). This was evident for 1 of 14 residents reviewed during a complaint survey. The findings include. A medical record is

the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #5's medical record

on 8/27/25 revealed the Resident was admitted to the facility in 2018 with a diagnosis to include cerebral infarction (stroke) and hemiplegia affecting left nondominant side. Hemiplegia is the total paralysis or severe loss of strength on one side of the body, affecting the arm, leg, and sometimes the face. It results from damage to the brain, often caused by stroke, brain tumors, or trauma. Review of Complaint 295996 on 8/27/25 revealed Resident #5 had lost his/her nursing home level of care, and the facility was looking into discharge options. During interview with the Social Services Assistant (SSA) on 8/27/25 at 11:49 AM, the SSA was asked about the Resident's loss of nursing home level of care. SSA stated he/she received notice

the Resident had lost his/her level of care, our Regional MDS (Minimum Data Set) Coordinator appealed

the findings in July 2025 and the Resident was again denied his/her level of care. SSA stated he/she had discussed the findings with Resident #5 and his/her representative. The Surveyor at that time asked for the paperwork submitted for nursing home level of care. Review of Resident #5's facility documentation provided to appeal the nursing home level of care revealed the documented diagnosis was personal history TIA (Transient Ischemic Attack) and Cereb Infarct (Stroke) no residual deficit. Further review of the facility documentation of electronic medical records submitted revealed it did include all of the Resident's diagnosis, including hemiplegia affecting left dominant side but this diagnosis was not included on the Resident's information sheet. Further review of Resident #5's medical record on 9/3/25 revealed no care plan meeting after April 2025 and no evidence of a discussion of loss of level of care in the Resident's medical record. On 9/3/25 at 11:50 AM, Social Services Assistant was asked for evidence of a care plan meeting since April 2025. On 9/3/25 at 12:25 PM the Social Services Assistant brought in evidence of a care plan meeting was held on 7/1/25 for Resident #5 on paper. During interview with Social Services on 9/3/25 at 12:25 PM, Social Services Assistant stated she keeps evidence of care plan meetings in her office, and the former Director of Nursing would upload the care plan meeting notes in the medical record but was unsure who was doing that now. During interview with the Regional MDS Coordinator (Staff #26)

on 9/3/25 at 12:50 PM, Staff #26 stated she would change the diagnosis to include Resident #5's hemiplegia. During interview with the Assistant Director of Nursing (ADON) on 9/3/25 at 1:40 PM confirmed

the facility staff failed to include Resident #5's July 2025 care plan meeting, and discussions with Resident and representative regarding loss of level of care in the medical record. The ADON also confirmed the diagnosis of no residual deficit was documented instead of left side hemiplegia. At that time the ADON stated the facility would be resubmitting paperwork for the Resident #5's nursing home level of care.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on record review and staff interviews, it was determined that the facility failed to correct and monitor quality deficiencies identified on the previous survey. This was evident for 3 out of 19 deficiencies reviewed

in the revisit survey. The findings include: On 11/13/2025 at 2:30 PM, A review of the survey teams findings revealed that the facility did not follow their plan of correction for 3 deficiencies (F-F610, F-F842, and S1320). Of

these 3 deficiencies, S1320 was found to still be in noncompliance.On 11/14/2025 at 8:06 AM, the Director of Nursing (DON) stated that the facility's Quality Assurance (QA) contact person was the Administrator.On 11/14/2025 at 8:45 AM, an interview with Administrator was conducted. When asked how often they hold QA meetings, the administrator stated every month. When asked if there was a QA meeting after the facility received the deficiencies from the Office of Health Care Quality, they stated that they did meet. When asked if the QA team/committee discussed the citations and progress of the plan of correction, the administrator stated not really because they have been working on correcting the deficiencies since the survey. This surveyor expressed concern that all the tags in the Plan of Correction stated that the QAPI team will review all of the audits. This surveyor made the administrator aware that the plan of correction was not followed for 3 deficiencies (F-F610, F-F842, and S1320), and the on going concern related to a qualified social worker.

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Denton Nursing and Rehab

420 Colonial Drive 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)

Federal health inspectors cited DENTON NURSING AND REHAB in DENTON, MD for a deficiency under regulatory tag F-F0921 during a complaint investigation conducted on 2025-09-04.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 10 deficiencies cited during this inspection of DENTON NURSING AND REHAB.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-06.