Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elon Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to honor resident choice regarding mobility and privacy. One resident with major depressive disorder and intact cognition had her power wheelchair removed despite prior documentation that she was cognitively and functionally able to use it, and no resident-centered plan, timeline, or communication was documented to facilitate its return; this led to frustration, anxiety, mental anguish, and self-isolation with psychological harm. Another resident with CIDP and major depressive disorder, care planned for a motorized wheelchair, was told before admission that electric wheelchairs were no longer allowed and was not permitted to use his own device, including for VA visits. A third resident with severe cognitive impairment was not allowed to close her door at night despite repeatedly expressing a preference for a quiet, dark environment for sleep, with staff insisting the door remain open for safety even though the items she placed behind the door were light and easily movable, and the DON later acknowledging the resident’s right to close her door.
Infection control practices were not followed during med pass and with shared equipment. An RN used her fingers to place tablets into med cups, did not perform HH at key points, and placed a wrist BP monitor on the med cart after use; another RN placed a BP monitor into a bag with clean supplies without disinfecting it first. The facility also had an uncleanable pipe in a shower room wrapped in cardboard and an uncovered plunger in another bathroom/shower room.
Loose hallway handrails were observed on the 2nd floor and in the one west hallway, with multiple rails moving and wiggling when grabbed. A resident using a wheelchair held onto a handrail that separated from the wall and ended up in the resident's hands. Staff and the NHA confirmed handrails were expected to be secure for resident use, but there was no documentation of routine handrail safety audits and no handrail policy was provided.
Failure to Notify POA of Significant Weight Loss: A resident with quadriplegia, dysphagia, protein calorie malnutrition, and PEG tube feeding experienced significant weight loss, dropping from 195 lbs. to 176 lbs. over a short period. Facility records noted the weight loss during IDT and dietary review, but the POA stated she was not aware of it and had not been contacted by the RD or facility staff, despite staff confirming the POA should have been notified of the change in condition.
A facility failed to maintain a clean, safe, and home-like environment in two resident rooms and one shower room. Surveyors observed a cockroach near a resident's call light, large holes and missing tile in a room floor and under-sink area, broken furniture, eroded wood, black spots on a toilet seat, and missing tile in the shower area. The NHA said renovations were underway but had no documentation for identified issues, purchase orders, completion timeframes, or work orders for the affected areas.
A resident admitted with dementia and additional diagnoses including mood disorder, depression, psychosis, and cognitive communication deficit had a Level I PASARR showing qualifying diagnoses, but no Level II was submitted. The SSD stated the resident was high functioning and did not need a Level II because the resident was able to explain what was going on and was not refusing psych services, despite the facility policy requiring PASARR screening and a new Level II evaluation when triggered by qualifying SMI/ID criteria.
Failure to Provide Nail Care as Part of ADL Assistance: A resident with cerebral infarction, generalized weakness, neuropathy, and bilateral above-knee amputations was observed with dirty, overgrown fingernails. Records showed the nails had previously been documented as needing clipping, but there was no documented refusal of personal hygiene care, and staff interviews indicated CNAs were responsible for nail care and daily hygiene. The DON stated hygiene care should be provided and refusals documented, but the resident’s nail care was not shown to have been completed.
The facility failed to provide safe respiratory care when one resident with COPD and respiratory failure was observed with an oxygen concentrator set above the ordered 2 L flow rate, and another resident was using oxygen without a physician order or care plan for oxygen therapy. Staff found the concentrators set at 4 L and 3 L, respectively, and the DON confirmed the second resident’s chart did not show an oxygen order.
Medication error rate exceeded 5 percent after surveyors observed 33 medication administration opportunities and identified two errors involving two residents. An LPN administered insulin from a Novolog FlexPen without priming the pen first, despite the manufacturer’s instructions and the resident’s sliding-scale order, and another LPN administered multiple scheduled medications to a resident, including midodrine with a hold parameter. The DON stated staff are expected to prime insulin pens before use, and the facility policy required comparing the MAR with the medication label before administration.
The facility failed to accurately manage residents' personal funds, with discrepancies in cost of care charges and missing Social Security deposits. Residents and their representatives raised concerns about potential fraudulent activity and inaccuracies in their accounts. The Nursing Home Administrator admitted to inaccuracies in the Resident Fund Management System, and the facility lacked a policy on accounting for residents' personal funds.
The facility failed to convey personal funds to three residents or their representatives within thirty days after discharge or death. A review of the Resident Fund Management Services (RFMS) showed that a resident had a balance of $3,814.35, another had $1,470.59, and a third had $340.54. The Nursing Home Administrator admitted the RFMS information was inaccurate and did not provide a policy for fund conveyance.
The facility failed to manage tube feeding services adequately for two residents, resulting in missing documentation and improper labeling of feeding products. Observations revealed that feeding setups lacked essential information such as product name, time, and rate of administration. The facility's policy on enteral tube management was not followed, leading to these deficiencies.
The facility failed to maintain an accurate accounting system for residents' personal funds, leading to discrepancies in cost of care withdrawals and Social Security deposits for several residents. Concerns were raised by residents and their representatives about potential inaccuracies and unauthorized withdrawals. The Business Office Manager responsible for these accounts had recently left, and no corrective actions were provided during the survey.
A resident's grievance regarding the payment of a phone bill was not resolved promptly by the facility. Despite multiple grievances filed by the resident's representative, the issue remained unresolved, leading to frustration and lack of reimbursement. The facility's grievance policy requires timely resolution, which was not met in this instance.
A resident's representative filed multiple grievances about the facility's failure to pay the resident's phone bill. Despite assurances from the business office and the former NHA that the bill was paid, the representative found it was not. The representative was told to pay the bill herself with a promise of reimbursement, which had not occurred, leading to ongoing frustration and unresolved grievances.
The facility failed to manage tube feeding services for two residents, with issues such as inaccurate dating and non-labeling of feeding products. One resident's care plan required specific feeding and water flushes, but records lacked documentation of these services. The feeding setup was incomplete, with the machine off and the bag missing essential information. The DON could not explain the missing initials in the records.
Failure to Honor Resident Choice for Power Wheelchair Use and Nighttime Door Privacy
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to self-determination and choice regarding mobility and privacy. One resident with major depressive disorder, muscle weakness, and intact cognition (BIMS 15/15) had previously been mobile and independent using a motorized wheelchair, as documented by occupational therapy and psychological notes. The facility removed this resident’s power wheelchair and did not document any resident-centered plan, communication of timelines, or expected outcomes to facilitate its return. After the removal, multiple progress notes from psychiatry, psychology, social services, nursing, and activities documented that the resident became largely self-isolative, spent most of the time in her room, refused to get out of bed or participate in activities, and repeatedly requested the return of the electric wheelchair. The DON confirmed the wheelchair had been taken away without options or timelines for regaining or maintaining its use, and the Administrator and DON did not provide details or a plan for reconsideration. A second resident with chronic inflammatory demyelinating polyneuropathy and major depressive disorder was also affected by the facility’s restriction on motorized wheelchairs. This resident was care planned to use a motorized wheelchair for mobility but reported being told on admission that electric wheelchairs were no longer allowed and that he could not use his own device, including for travel to the Veterans Administration. The Admissions Coordinator and Administrator confirmed that, prior to admission, the resident was informed he could not have his motorized wheelchair in the facility. There was no documentation in the record that the facility promoted or facilitated this resident’s use of a motorized wheelchair to support mobility and independence, despite the care plan indicating such use. The facility also failed to support another resident’s choice to close her room door at night for privacy and personal comfort. This resident, who had a cognitive communication deficit and a severely impaired BIMS score of 4/15, stated through her daughter that she wanted the door closed at bedtime because she disliked the noise and lights when trying to sleep, but staff told her the door had to remain open so they could see that she was breathing. A CNA confirmed that staff told the resident the door must stay open for her safety and cited concern that the resident sometimes placed a TV tray or overbed table behind the door, although the CNA acknowledged these items were light, easily movable, and may not be tall enough to block the door. An RN stated she had been told the resident was not allowed to close her door, and further stated that if it was the resident’s preference to close the door at night, it was her right to have privacy and comfort in her home. The DON confirmed that the resident has the right to close her door at night if that is her choice. The facility’s failure to promote and facilitate the use of electric wheelchairs for two residents and to honor one resident’s preference to close her door at night resulted in a lack of support for resident choice, independence, and privacy. For one resident, this failure caused frustration, anxiety, mental anguish, and self-isolation, which resulted in psychological harm.
Infection Control Failures With Hand Hygiene, Shared Equipment, and Shower Room Surfaces
Penalty
Summary
Infection prevention and control practices were not followed during medication administration and use of shared equipment. During observation, an RN used her fingers to place vitamin D-3, aspirin, iron, sodium chloride, vitamin B-12, and sodium bicarbonate tablets into medication cups for residents. After preparing medications, the RN did not perform hand hygiene before entering a resident’s room, put on gloves to resecure an ace bandage, removed the gloves, did not perform hand hygiene again, and then administered medications. The RN also used a wrist blood pressure monitor on one resident and then placed the machine directly on top of the medication cart. Another RN was observed leaving a resident room with a wrist blood pressure monitor and placing it in a bag with clean medical supplies; she stated the monitor should have been disinfected first. The RN stated red-top disinfectant wipes were available, and when asked about removing over-the-counter medications from containers, she said, “I touched them.” The facility also had an uncleanable surface in a shower room. In one west, a shower area had a long pipe extending from the ceiling to the floor that was wrapped in cardboard. A separate bathroom/shower room had a plunger next to the toilet that was not covered in a bag. The DON stated the pipe should not have cardboard on it because cleanable surfaces need to remain cleanable, and said the cardboard had been used to prevent residents from being burned by the heating pipe. She also stated that plungers are expected to be covered, and if used, should be sanitized and returned to a bag.
Loose Hallway Handrails Not Secured to Wall
Penalty
Summary
Loose hallway handrails were observed on the 2nd floor during multiple facility-wide tours, including handrails before the shower room, across from the nurse station and below the mirror and clock, on the right side of the nurse's station door, between several resident rooms, on the left side of a resident room, on the right side of the storage closet before the dining room, and on the right side of the soiled utility room across from a resident room. The observations showed the entire length of these wooden handrails moved and wiggled and had physical play when grabbed. Residents were observed using these handrails while ambulating around the building during the 7-3 a.m. and 3-11 p.m. shifts on multiple days. During an observation on the one west hallway, a resident was seen ambulating in a wheelchair while holding the handrail with the right hand, and the handrail separated from the wall and was observed in the resident's hands. Staff interviews confirmed that handrails were expected to be secured to the wall for safe resident use, that staff were to report loose handrails through the work order system, and that maintenance staff checked handrails by pulling on them. The maintenance technician and the NHA stated there was no documentation showing the handrails were audited for safety and maintenance, and the facility did not provide a handrail policy.
Failure to Notify POA of Significant Weight Loss
Penalty
Summary
The facility failed to notify the resident’s POA of a significant change in condition related to weight loss for a resident with multiple complex diagnoses, including quadriplegia, dysphagia, protein calorie malnutrition, and gastrostomy feeding. The resident was admitted and later readmitted to the facility, had a medical and financial POA, and was dependent on staff for all ADLs. Weight records showed the resident weighed 195 lbs. on 12/27/2025, 1/13/2026, and 2/10/2026, then dropped to 180 lbs. on 2/17/2026 and 176 lbs. on 2/24/2026, reflecting a total loss of 19 lbs. and a 7.37% loss in one month. The POA stated she was involved in the resident’s care and attended care plan meetings, but she was not aware of the weight loss and had not been contacted by the facility’s RD regarding nutritional concerns. Facility documentation showed the resident’s weight loss was noted during an IDT care plan review and later in dietary notes and an RD assessment, which identified additional weight loss and new interventions. Interviews with the RD, DON, and NHA confirmed the resident had a significant weight loss and that the POA should have been notified of the change in condition, but the record did not show that this notification occurred.
Unsafe and Unclean Resident Rooms and Shower Area
Penalty
Summary
The facility did not ensure a clean, safe, and home-like environment in two resident rooms and one shower room. In room 103, an observation at 9:38 a.m. found a cockroach crawling next to the call light on the floor by the resident's bed and bedside table. In room 201, observations at 12:18 p.m. found a large hole in the floor between the resident's bed and dresser with wood and unidentifiable material exposed, missing tile pieces, a large hole under the sink exposing pipes and wood, cracked tile pieces, painter's tape separating from the wall, a clear thin plastic sheet covering part of the hole, a white dresser with a long-broken piece of wood at the bottom, and eroded wood with missing paint around the a/c unit by the window. In the shower room next to room 201, an observation at 9:30 a.m. found multiple black spots on the toilet seat and bar underneath, along with a small ledge in the shower area with missing tile exposing hardened, unidentifiable material underneath. The Nursing Home Administrator stated the facility was completing renovations, including replacing floor surfaces and resident room furniture, repainting walls, and repairing windowsills and window frames, but confirmed she did not have documentation showing when the renovation was identified, purchase orders, or completion timeframes. She also stated she was not aware of the environmental concerns in room 201 or the bathroom/shower room and confirmed there was no documentation of work orders for those areas.
Failure to Complete PASARR Level II Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
Facility failed to complete or update PASARR screening requirements for a resident with mental health diagnoses after qualifying diagnoses were identified. Resident #5 was admitted with a primary diagnosis of dementia and also had Parkinsonism, mood disorder, depression, psychosis, and cognitive communication deficit. A Level I PASARR dated 9/11/25 showed qualifying diagnoses, but the review indicated that the Level I PASARR was complete and that a Level II was not submitted for consideration following the qualifying diagnoses. During interview, the Social Service Director stated Resident #5 did not need a Level II PASARR because the resident was functioning, able to explain everything going on, and not refusing psychology services. She said that refusal of care, services, medications, or trying to harm self would indicate a need for a PASARR Level II referral. The facility policy stated that all residents must have a PASARR screen upon admission and that residents previously identified with Serious Mental Illness and/or Intellectual Disability who experience a significant change in status require a new PRI and SCREEN, with a new Level II PASARR evaluation if triggered.
Failure to Provide Nail Care as Part of ADL Assistance
Penalty
Summary
The facility failed to ensure ADL care related to nail care was provided for one resident. On 02/22/2026, Resident #9 was observed with brown and red substances underneath the fingernails, and the fingernails were about half an inch past the fingertips. The resident had diagnoses including cerebral infarction, generalized muscle weakness, hereditary and idiopathic neuropathy, other lack of coordination, and bilateral above-knee amputations. The resident’s BIMS score was 14, indicating intact cognitive function with little to no memory or thinking impairment. Record review showed no documented refusals of personal hygiene care for January 2026, and February 2026 ADL sheets were not provided. Shower assessment sheets for December 2025 and January 2026 showed the fingernails were clean on some dates, and on 12/22/2025 and 12/25/2025 the nails were documented as needing to be clipped. The care plan identified the resident as requiring substantial to total staff assistance with ADL care due to generalized weakness and bilateral above-knee amputation. Staff interviews indicated CNAs were responsible for personal hygiene and nail care, that nail care should be documented and provided during showers, and that the resident often delayed personal hygiene care due to fatigue after dialysis. The DON stated residents should receive daily hygiene care and that refusals should be documented and reported, but she had not observed the resident’s nails and was unsure of any refusal history. The facility did not provide a policy and procedure for ADL care.
Oxygen Orders Not Followed and Missing for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not following physician orders for oxygen for one resident with COPD, COPD exacerbation, acute and chronic respiratory failure with hypoxia, and centrilobular emphysema. The resident was observed with an oxygen concentrator set at 4 L, while the order summary listed oxygen at 2 L per minute via nasal cannula every shift and oxygen saturation checks as needed. Staff later observed the concentrator set at 4 L and adjusted it back to 2 L. The DON stated the resident was alert and oriented and should have been able to explain how the concentrator became set to a different flow rate than ordered. The facility also failed to ensure another resident had physician orders for oxygen use. That resident was observed wearing a nasal cannula with an oxygen concentrator set at 3 L, but the order summary did not show any physician order for oxygen and there was no care plan for oxygen therapy. Staff were unable to produce orders or a care plan related to oxygen therapy, and the DON confirmed the resident’s orders did not reveal an oxygen order, although paper oxygen orders were later provided. The DON stated the resident had been admitted with hospital orders for oxygen at 2 L via nasal cannula and was not in respiratory distress upon admission.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5.00%. During 33 observed medication administration opportunities, surveyors identified two errors involving two residents, resulting in a 6.06% medication error rate. One error occurred during insulin administration for a resident with diabetes mellitus when an LPN removed a Novolog FlexPen, verified the insulin type and expiration, attached a new needle, dialed the dose to 4 units, cleaned the site, and administered the medication without priming the pen first. The resident’s order was for Novolog FlexPen 100 unit/ml by sliding scale, and the manufacturer’s instructions required priming the pen before selecting and injecting the dose. After the administration, the LPN acknowledged that the insulin pen should have been primed. A second error was observed during medication administration for another resident when an LPN administered multiple medications, including aspirin, midodrine hydrochloride, roflumilast, prednisone, bumetanide, allopurinol, potassium chloride ER, dapagliflozin, and guaifenesin/dextromethorphan. The resident’s order summary showed that midodrine hydrochloride 5 mg was ordered three times daily with instructions to hold if systolic blood pressure was greater than 130. The DON stated that for over-the-counter medications, staff are required to notify the physician of any medications currently on hand and obtain a corresponding order, and that staff are expected to prime the insulin injector pen prior to administration. The facility policy stated medications are to be administered as prescribed and that the MAR is to be compared with the medication label before administration.
Inaccurate Management of Resident Funds
Penalty
Summary
The facility failed to maintain an accurate and up-to-date system for managing residents' personal funds, affecting three residents. The review of accounts for these residents showed discrepancies between the cost of care withdrawn from their personal funds and what was determined by Medicaid Access eligibility. Additionally, Social Security direct deposits for January and February 2025 were not reflected in the accounts, leading to concerns about the accuracy of the residents' balances. Interviews with residents and their representatives revealed concerns about potential fraudulent activity and inaccuracies in the resident trust fund accounts. One resident expressed worry about the accuracy of her balance after noticing irregularities in the payments for her room and board. Another resident's representative suspected fraudulent activity after a significant amount was withdrawn from the account without authorization. A grievance was filed by another resident requesting a report of fund transactions, which led to the discovery of an unexplained cost of care payment. The Nursing Home Administrator acknowledged the inaccuracies in the Resident Fund Management System (RFMS) and noted that the Business Office Manager, who was responsible for handling the resident trust accounts, had recently left the position. The facility was unable to provide a policy on the accounting of residents' personal funds or any corrective action taken to address the irregularities in the resident trust fund accounts during the survey.
Plan Of Correction
Resident #3, #5, and #6 cost of care was verified with the Medicaid access eligibility portal and verified to match the Resident Fund Management Services (RFMS). A finance coordinator was hired on to ensure oversight and maintenance of the Resident Fund Management Services. Social Security deposits were found, added to account, and balanced for Residents #3, #5, and #6. Resident #5 cost of care payment of $3,015.60 was verified and accurate. Resident #5 patient liability for 2025 was updated based off of the Medicaid Access system. Resident #3 RFMS account was reconciled and patient liability amount updated. Resident #6 RFMS account was reconciled, patient liability updated, and debit was explained to resident and responsible party. All residents with personal funds accounts were audited to ensure the correct resident cost of care was accurate and in Resident Fund Management Services. Findings were corrected and accounts reconciled to reflect accurate amounts and balances. Residents that have been discharged for the past 30 days, accounts were closed out in RFMS and refunds sent to responsible party/resident. Quality measure audit tool was completed on all active residents with a personal funds account to ensure the facility is maintaining a system that assures a full and complete and separate accounting according to general accounting principles of each resident's personal funds entrusted to the facility on the resident's behalf. The Nursing Home Administrator was re-educated by the COO to ensure the facility is maintaining a system that assures a full and complete and separate accounting according to general accounting principles of each resident's personal funds entrusted to the facility on the resident's behalf. The Nursing Home Administrator or designee will complete quality reviews weekly for 4 weeks, then monthly for 2 months thereafter to ensure ongoing and sustained compliance. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 2 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
Failure to Convey Resident Funds Timely
Penalty
Summary
The facility failed to ensure that personal funds deposited with the facility were conveyed to the resident or their representative within thirty days after discharge or death for three residents. The review of the facility's Resident Fund Management Services (RFMS) on 02/19/2025 revealed that Resident #4, #7, and #8 had balances of $3,814.35, $1,470.59, and $340.54, respectively. Resident #4 was discharged to the community on 12/17/2024, Resident #7's discharge date was not specified, and Resident #8 was discharged on 10/04/2024. During an interview, the Nursing Home Administrator (NHA) acknowledged that the RFMS information was inaccurate but did not provide alternative information or a policy for the conveyance of personal funds. No policy was provided during the survey, indicating a lack of proper management and timely return of resident funds.
Plan Of Correction
Resident #4, #7, #8 personal funds accounts were reconciled, closed out, then issued the balance. A finance coordinator was hired with a responsibility of maintaining resident funds accounts. Current residents with personal funds accounts were audited. Findings were corrected and accounts reconciled to reflect accurate amounts and balances. Residents that have been discharged for the past 30 days, accounts were closed out in RFMS and refunds sent to responsible party/resident. Nursing home administrator was re-educated by COO to ensure residents with personal funds deposited with the facility were conveyed to the resident or resident representative within 30 days after discharge. The Nursing Home Administrator or designee will complete quality reviews weekly for 4 weeks, then monthly for 2 months thereafter to ensure ongoing and sustained compliance. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
Deficiencies in Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to ensure proper management of tube feeding services for two residents, leading to deficiencies in documentation and labeling. For one resident, the flow sheet lacked documentation of water flushes and tube feeding administration on multiple dates. During an observation, the tube feeding machine was found to be off, and the feeding bag lacked essential information such as the product name, time, and rate of administration. The Licensed Practical Nurse (LPN) on duty admitted to transferring the product from its original packaging due to a tubing issue, which was not completed by the previous nurse. For another resident, the tube feeding setup was observed with an empty bottle that lacked documentation of the rate, and the bottle was not labeled with the time it was hung. A subsequent review with the Director of Nursing (DON) revealed a full bottle with missing time and rate information. The facility's policy on enteral tube management, which includes responsibilities such as assessing tube placement and administering feedings, was not adhered to, as evidenced by the lack of proper labeling and documentation.
Plan Of Correction
A new was immediately hung, verified, dated, and timed by the licensed Nurse for residents #1 and #9. The Director of Nursing immediately completed quality review for residents #1 and #9 to ensure is being provided in accordance with the MD order accurate product, hang time, rate, and date is clearly displayed. Complete quality review of current residents within the facility receiving feeding to ensure accuracy of following MD order for feeding as follows; accurate product, hang time, rate, and date is clearly displayed on containers. Revision of current policy and procedure for feed. The Director of Nursing or designee will re-educate the current licensed nurses on the tube management policy and procedure and the nurse's responsibilities when caring for a resident with an. The Director of Nursing or designee will complete quality reviews daily for 2 weeks, weekly for 4 weeks, then monthly for 2 months. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
Inaccurate Accounting of Resident Funds
Penalty
Summary
The facility failed to maintain an accurate and up-to-date accounting system for residents' personal funds, as required by state regulations. This deficiency was identified through observations, record reviews, and interviews with residents and their representatives. Specifically, the facility's Resident Funds Management System (RFMS) did not accurately reflect the cost of care withdrawals and Social Security direct deposits for three residents. For instance, Resident #6 expressed concerns about the accuracy of her trust fund balance, noting discrepancies in room and board payments. Similarly, Resident #3's representative suspected fraudulent activity after a $500 withdrawal from the resident's account. Additionally, a grievance filed by Resident #5 highlighted inconsistencies in fund transactions, with a noted withdrawal that did not align with the expected cost of care. The review of the residents' financial records revealed that the cost of care charges did not consistently match the patient liability amounts determined by Medicaid Access. For example, Resident #5's account showed a withdrawal of $3015.60, which was inconsistent with the Medicaid-determined liability of $1,790.60 per month. Furthermore, the facility's Business Office Manager, who was responsible for handling resident trust accounts, had recently left the position, leaving the facility without a person in charge of these accounts. The Nursing Home Administrator acknowledged the inaccuracies in the RFMS and mentioned a Performance Improvement Plan, but no corrective actions were provided to the survey team during the survey.
Plan Of Correction
Resident #3, 5, and 6 cost of care was verified with the Medicaid access eligibility portal and verified to match the Resident Fund Management Services (RFMS). A finance coordinator was hired on to ensure oversight and maintenance of the Resident Fund Management Services. Social Security deposits were found, added to account, and balanced for Residents #3, #5, and #6. Resident #5 cost of care payment of $3,015.60 was verified and accurate. Resident #5 patient liability for 2025 was updated based off of the Medicaid Access system. Resident #3 RFMS account was reconciled and patient liability amount updated. Resident #6 RFMS account was reconciled, patient liability updated, and debit was explained to resident and responsible party. All residents with personal funds accounts were audited to ensure the correct resident cost of care was accurate and in Resident Fund Management Services. Findings were corrected and accounts reconciled to reflect accurate amounts and balances. Residents that have been discharged for the past 30 days, accounts were closed out in RFMS and refunds sent to responsible party/resident. Quality measure audit tool was completed on all active residents with a personal funds account to ensure the facility is maintaining a system that assures a full and complete and separate accounting according to general accounting principles of each resident's personal funds entrusted to the facility on the resident's behalf. The Nursing Home Administrator was re-educated by the COO to ensure the facility is maintaining a system that assures a full and complete and separate accounting according to general accounting principles of each resident's personal funds entrusted to the facility on the resident's behalf. The Nursing Home Administrator or designee will complete quality reviews weekly for four (4) weeks, then monthly for 2 months thereafter to ensure ongoing and sustained compliance. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for two (2) months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure a prompt resolution to a grievance for a resident, as evidenced by multiple unresolved grievances related to the payment of the resident's phone bill. The resident's representative initially filed a grievance on November 18, 2024, requesting the facility to pay the phone bill. Although the former Nursing Home Administrator signed off that the bill had been paid and the grievance resolved on November 26, 2024, the representative later discovered that the bill was not fully paid. This led to a second grievance being filed on December 16, 2024, which was again marked as resolved by the former NHA on December 18, 2024. Despite these actions, the issue persisted, and a third grievance was filed on February 1, 2025, after the representative was instructed to pay the bill herself with the promise of reimbursement. As of February 19, 2025, the representative had not been reimbursed, and she expressed frustration over the lack of response from the facility. The facility's grievance policy, revised in June 2023, mandates that grievances be addressed in a timely manner, which was not adhered to in this case.
Plan Of Correction
The Social Services Director spoke with resident #3's responsible party to communicate the facility's effort to a prompt resolution. The phone bill monies were withdrawn from resident #3's personal funds account and reimbursed to the responsible party. The facility will manage resident #3's monthly phone bill going forward. The facility will manage residents' personal accounts for those that the facility is the designated payee. The Social Services Director and Nursing Home Administrator conducted a complete audit of all grievances in the past 2 months to ensure accuracy and prompt resolutions. No further corrections were identified. The Social Services Director or designee will conduct interviews of 4 random residents/responsible parties 5 times a week for 2 weeks, then 2 times a week for 4 weeks, then monthly for 2 months. The Social Services Director was re-educated by the Nursing Home Administrator to ensure a prompt resolution to a resident grievance. The Social Services Director or designee will re-educate the current staff on the resident grievance policy and procedure and accurate use of the grievance form with prompt resolution. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
Failure to Resolve Resident Grievance Regarding Phone Bill Payment
Penalty
Summary
The facility failed to ensure a prompt resolution to a grievance for one of the sampled residents. The resident's representative filed multiple grievances regarding the payment of the resident's phone bill. Initially, the representative was informed by the business office that the bill would be paid, but it was not. The grievance form indicated that the former Nursing Home Administrator had signed off that the bill was paid and the grievance resolved, but this was not the case. Subsequent grievances were filed by the representative, expressing frustration that the phone bill was not completely paid and that she was told to pay the bill herself with the promise of reimbursement. Despite the grievance log reflecting that the issue was resolved, the representative reported that she had not been reimbursed and was not receiving responses from the facility. The Social Service Director and the current Nursing Home Administrator were involved in addressing the grievances, but the issue remained unresolved at the time of the report.
Plan Of Correction
The Social Services Director spoke with resident #3's responsible party to communicate the facility's effort to a prompt resolution. The phone bill monies were withdrawn from resident #3's personal funds account and reimbursed to the responsible party. The facility will manage resident #3's monthly phone bill going forward. The facility will manage residents' personal accounts for those that the facility is the designated payee. The Social Services Director and Nursing Home Administrator conducted a complete audit of all grievances in the past 2 months to ensure accuracy and prompt resolutions. No further corrections were identified. The Social Services Director or designee will conduct interviews of 4 random residents/responsible parties 5 times a week for 2 weeks, then 2 times a week for 4 weeks, then monthly for 2 months. The Social Services Director was re-educated by the Nursing Home Administrator to ensure a prompt resolution to a resident grievance. The Social Services Director or designee will re-educate the current staff on the resident grievance policy and procedure and accurate use of the grievance form with prompt resolution. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
Inadequate Management of Tube Feeding Services
Penalty
Summary
The facility failed to ensure adequate management of services for two tube-fed residents, as evidenced by inaccurate dating and non-labeling of feeding products. For one resident, the care plan required specific feeding and water flushes, but the flow records lacked documentation of these services being performed at the prescribed times. Additionally, the feeding setup was observed to be incomplete, with the machine turned off and the feeding bag lacking essential information such as the product name, time, and rate of administration. During a review with the Director of Nursing, it was noted that there were blanks in the flow records, and the DON was unable to explain why staff had not initialed the records. An observation of the resident's feeding setup revealed that the bag was filled to the 1000 mark but did not have the necessary labeling, which is crucial for ensuring proper administration and tracking of nutritional intake.
Plan Of Correction
A new was immediately hung, verified, dated, and timed by the licensed Nurse for residents #1 and #9. The Director of Nursing immediately completed quality review for residents #1 and #9 to ensure is being provided in accordance with the MD order accurate product, hang time, rate, and date is clearly displayed. Complete quality review of current residents within the facility receiving feeding to ensure accuracy of following MD order for feeding as follows; accurate product, hang time, rate, and date is clearly displayed on containers. Revision of current policy and procedure for feed. The Director of Nursing or designee will re-educate the current licensed nurses on the tube management policy and procedure and the nurse's responsibilities when caring for a resident with an. The Director of Nursing or designee will complete quality reviews daily for 2 weeks, weekly for 4 weeks, then monthly for 2 months. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ybor City Center For Rehabilitation And Healing | 0.9 mi | ★★★★★ | 3 | 0 |
| Whispering Oaks | 1 mi | ★★★★★ | 11 | 0 |
| Rehabilitation And Healthcare Center Of Tampa | 2.8 mi | ★★★★★ | 1 | 0 |
| Aviata At The Bay | 2.9 mi | ★★★★★ | 3 | 2 |
| Canterbury Towers Inc | 5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.