Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Aspen Hill Rehabiliation & Healthcare Center during CMS and state inspections, most recent first.
Failure to provide ordered dental services: two residents did not receive needed dental follow-up after dentist evaluations and recommendations. One resident with dementia had repeated recommendations for multiple extractions, ongoing mouth pain, and inflamed gums, but the teeth were not removed for an extended period amid unclear staff responsibility and missed follow-up. Another resident with cognitive impairment had severe periodontitis and recommended extractions after an initial dental exam, but no further treatment occurred because the resident was not seen again after insurance-related communication problems.
Missing psychotropic consent for a resident with dementia, anxiety, and depression. The resident had a BIMS score of 7/15 and was prescribed Mirtazapine, Lorazepam, and Duloxetine, but the medical record did not show any psychotropic consents. The DON stated the facility could not locate the consents and had sent new forms to the guardian for signature.
A resident with mild cognitive impairment, schizophrenia, and routine antipsychotic use had a court-appointed guardian and treatment plan authorizing antipsychotic medication, but the plan expired and was not current in the record. The SW said the guardian did not petition the court for review, and the admin later learned the plan had been expired for nearly 7 months.
A resident with dysphagia, psychotic disorders, and moderate cognitive impairment required 1:1 supervision with meals and wrist weights for all meals, per the care plan, physician order, Kardex, and ST discharge summary. Surveyors observed the resident eating breakfast in the room on a bedside table without supervision, without the wrist weights in place, and with food scattered on the floor and on the resident. Staff also documented most breakfast episodes as set-up only, and the DON, UM, and nurse acknowledged that the ordered meal supervision and adaptive equipment were not being followed.
Inaccurate oxygen flow rate documentation: A resident with asthma, chronic respiratory failure, and heart failure was observed receiving O2 via NC at 4 to 4.5 L, but the MAR documented 2 L. The chart contained conflicting O2 orders, and nursing, RT, and the DON stated the resident had actually been receiving 4 L while staff continued signing off on 2 L.
A resident with multiple health conditions required staff assistance for ambulation, as per their care plan. However, a CNA allowed the resident to ambulate independently, resulting in a fall and injury. The CNA had not reviewed the resident's Kardex and mistakenly believed the resident was independent. Other staff were either unaware of the resident's needs or not present during the incident.
A resident at risk for falls, requiring assistance with ambulation, was left unsupervised and fell, resulting in a laceration requiring hospital treatment. The CNA on duty was unable to assist due to other responsibilities and attempts to alert a nurse were unsuccessful. The incident highlights a failure in staff communication and supervision.
A resident reported rough handling by a CNA, but the facility did not take immediate action, leading to another incident where a different resident suffered a fracture due to the same CNA's actions. The facility's failure to follow its abuse prevention and investigation policies resulted in continued risk to residents.
A facility failed to investigate an allegation of rough handling by a CNA, reported by a resident with intact cognition. The incident was not documented or thoroughly investigated, allowing the CNA to continue working. This led to another incident where the same CNA was reported for rough handling, resulting in a resident's arm fracture. The facility's inadequate response to the initial report violated its policy on abuse investigation.
The facility failed to meet professional standards for four residents, including not applying physician-ordered compression stockings, incorrect g-tube flush settings due to unclarified orders, lack of speech therapy evaluation for diet consistency, and missing scheduled weigh-ins for a resident at risk of malnutrition.
The facility failed to maintain sufficient staffing levels on weekends, as indicated by the PBJ report for FY Quarter 4, 2024. The report showed excessively low weekend staffing, triggering a concern for follow-up. The facility's staffing plan required 15 licensed nurses and 30 nurse aides, with 3.20 HPPD for direct care, but this was only met in one out of 12 weeks. The Administrator noted past recruitment difficulties, though staffing has improved with on-call nursing management.
The facility failed to label and date medications according to guidelines, with several medications found open and undated on two medication carts. Additionally, a medication cart on the Dementia Unit was left unlocked and unattended. Staff interviews confirmed the need for proper labeling and secure storage of medications.
The facility failed to schedule recommended specialist appointments for cataract surgery for three residents, despite recommendations from a consulting eye doctor. The residents expressed frustration over worsening vision, and the outpatient eye doctor's office confirmed no referrals were received. The Director of Nurses expected follow-ups within a week, but this was not done, indicating a lapse in managing specialist referrals.
The facility failed to ensure accurate documentation and medication administration for several residents. One resident's oxygen settings and equipment changes were inaccurately documented, while another's antipsychotic medication lacked an associated diagnosis. A diabetic resident received insulin later than documented, and another resident's blood pressure was recorded from the wrong arm. These discrepancies were confirmed through observations and staff interviews.
A facility failed to investigate an abuse allegation from a resident, leading to further abuse by the same CNA. The resident reported rough handling and incorrect brief sizing, but the incident was treated as a grievance. The facility's policy requires thorough investigation and reporting, which was not followed. Another resident later reported physical abuse by the same CNA, resulting in pain and a fracture. The CNA was eventually terminated, but the initial failure to investigate allowed further harm.
A resident reported rough handling by a CNA during a transfer, including being forced to use an incorrect size brief. The facility failed to report the incident as potential abuse, categorizing it instead as a customer service issue. The incident was not documented in the medical record or reported to authorities, contrary to facility policy.
A facility failed to implement a comprehensive care plan for a resident with cognitive impairment and a history of falls, neglecting to use fall mats as specified. Despite multiple falls and injuries, staff were unaware or unable to locate the mats, highlighting a disconnect between the care plan and its execution.
A resident with congestive heart failure did not have daily weights obtained for three consecutive days due to a broken scale, leading to a 5.2-pound weight gain. The facility staff failed to use alternative scales, and management was unaware of the issue until it was documented in nursing progress notes.
A facility failed to obtain a physician's order for the appropriate settings of an air mattress for a resident with pressure ulcers. The resident, with moderate cognitive impairment and weighing 148.7 lbs, was observed on an air mattress set at 175 lbs. Staff interviews revealed that the mattress should be set according to the resident's weight to prevent skin breakdown, but no physician's order was present to guide the settings.
A resident's PICC line dressing was not changed as required, and weekly measurements were not taken to ensure the line had not migrated. The LPN involved was not trained to change PICC line dressings, leading to a deficiency in care.
A facility failed to adhere to a physician's orders for a resident with Acute Respiratory Failure, providing oxygen at 3L instead of the prescribed 2L, not changing the oxygen tubing as scheduled, and omitting foam ear protectors. Documentation inaccurately reflected compliance, while observations and staff interviews confirmed the discrepancies.
The facility failed to develop trauma-informed care plans with resident-specific triggers and interventions for two residents with PTSD. One resident had intact cognition but was inaccurately assessed as not having past trauma, while another had severe cognitive impairment with a care plan lacking specific interventions. Interviews revealed acknowledgment of assessment inaccuracies and expectations for resident-specific care plans.
A resident with Parkinson's Disease, malnutrition, and depression was not provided with necessary dental care despite the facility's policy. The resident, who had multiple missing and carious teeth, reported not seeing a dentist since admission and expressed a desire for dental services to aid in chewing. The facility's documentation noted missing teeth but did not address carious teeth, and there was no record of a dental consult. The DON acknowledged the oversight.
A resident with moderate cognitive impairment did not receive necessary dental care after a dentist recommended tooth extractions and new dentures. The facility failed to follow up on these recommendations, resulting in the resident not receiving the required dental services. Staff were unaware of the need for extractions and dentures, and there was no documentation or communication regarding the dental visit and recommendations.
The facility failed to develop a QAPI plan after two residents alleged abuse by the same CNA. Despite the facility's policy requiring investigation and reporting of abuse, the QAPI plan was incomplete, with no audits or safety measures implemented. The CNA was terminated for insubordination, but the Administrator could not provide evidence of resident safety interviews or a complete QAPI plan.
The facility failed to implement contact precautions for two residents diagnosed with C. difficile and MRSA. Despite signs indicating the need for PPE, staff were observed entering and exiting rooms without proper protective measures or hand hygiene. Interviews revealed a lack of adherence to infection control protocols, compromising the facility's infection prevention efforts.
The facility failed to offer the COVID-19 vaccine to two employees during their new hire orientation, as required by policy. Both employees were informed about the vaccine and refused it, but the forms were not properly completed. The oversight occurred during the orientation sessions, and both employees have been working in the facility since then.
The facility inaccurately completed MDS assessments for two residents, leading to documentation deficiencies. One resident's dental status was misrepresented, showing no carious teeth despite having multiple missing and discolored teeth. Another resident's MDS failed to indicate a feeding tube, despite it being part of their care plan. These errors were acknowledged by the facility's nursing staff.
Failure to Provide Ordered Dental Services
Penalty
Summary
The facility failed to provide dental services for two residents. For one resident with chronic obstructive pulmonary disease, chronic respiratory failure, and dementia, the contracted dentist documented repeated recommendations over time for extraction of multiple remaining teeth, but the extractions were not completed for an extended period. The resident reported ongoing mouth pain, difficulty chewing, and waiting months for dentures after being told teeth needed to be removed first. Survey observations found seven teeth worn down to the gumline with black markings and reddened, inflamed gums, and later notes continued to show severely inflamed tissue and remaining root tips that had not been removed. The dentist’s records showed a progression of recommendations, including referral to oral surgery, later recommendations to extract remaining teeth, and repeated follow-up notes stating the teeth had still not been extracted. Facility documentation showed a consent for extraction signed by the resident’s legal guardian, but staff interviews indicated confusion about who was responsible for arranging appointments and follow-up. The DON stated she had not seen nursing documentation about dental follow-up for the resident and was not familiar with the dentist’s recommendations. The medical records staff said she was responsible for outside appointments but was not aware of any dental appointments needed, and the consulting dental company reported repeated attempts to obtain prior authorization without response. A second resident, with diagnoses including mild cognitive impairment, hypertension, schizophrenia, and anemia, was observed with missing and broken teeth on the top and bottom. The resident had a signed consent for dental services and an initial dental exam that documented generalized severe periodontitis, severely mobile teeth, and recommendations for extraction of two teeth, along with routine preventive care. However, the survey found no further dental treatment after that initial exam, and staff interviews showed they did not realize the resident had not been seen again because of insurance-related communication issues. The DON and Administrator acknowledged that the resident had been placed on a do-not-treat list by the dental provider due to insurance verification issues, and the facility had not identified that the recommended dental services had not been provided for over a year.
Missing Psychotropic Consent for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to obtain the necessary psychotropic consent for one resident out of a sample of 27. Facility policy titled Psychotropic Medication Use, revised February 2025, required staff and the physician to review the resident's or representative's right to accept or decline treatment before initiating, increasing, or switching a psychotropic medication and to obtain documented consent or refusal. Resident #44 was admitted in June 2023 with diagnoses including dementia, anxiety, and depression, and the MDS indicated a BIMS score of 7 out of 15, showing severe cognitive impairment. The resident's physician orders showed prescriptions for Mirtazapine 7.5 mg, initiated 5/31/25, Lorazepam 0.5 mg, initiated 11/6/25, and Duloxetine Hydrochloride 60 mg, initiated 6/8/23. Review of the medical record did not show any psychotropic consents, and during interview the DON stated the facility could not locate the consents and had sent new consents to the resident's guardian for signature.
Expired Court-Ordered Treatment Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that an advance directive was current and not expired for one resident. Resident #20 was admitted with diagnoses including mild cognitive impairment, hypertension, schizophrenia, and anemia, and the most recent MDS showed moderately impaired cognition with routine antipsychotic medication use. The resident’s record included a care plan noting a court-appointed guardian and a court order authorizing treatment with antipsychotic medication under a treatment plan that was to be reviewed on or before a specified date. Review of the medical record showed that the court-appointed treatment plan for antipsychotic medication had expired and there was no current, unexpired treatment plan on file. During interviews, the social worker stated she learned the treatment plan had expired and that the guardian did not petition the court for review. The administrator stated she became aware of the expired treatment plan sometime later, and the report states the facility failed to petition the court before the expiration date, leaving the resident with an expired court-appointed treatment plan for nearly over 7 months.
Failure to Provide Ordered Meal Supervision and Adaptive Equipment
Penalty
Summary
The facility failed to ensure that activities of daily living were provided for one resident, identified in the report as Resident #79, who required assistance with eating. The resident was admitted with diagnoses including cervical disc disorder, dysphagia, and psychotic disorders, and the most recent MDS indicated moderate cognitive impairment with a need for supervision or touching assistance with eating. The resident’s care plan directed 1:1 supervision with meals, use of wrist weights for all meals, and seating at a sturdy table rather than a bedside table. During observations, Resident #79 was seen eating breakfast in the room while seated in a wheelchair with the meal tray placed on a bedside table. On one occasion, there were multiple scraps of dropped food under the table and eggs on the resident’s chest, with a pink wrist weight next to the tray. On another occasion, staff set up the breakfast tray and left the room, and the resident ate without supervision or assistance for several minutes, was not wearing the wrist weight, and food scraps were observed on the floor beneath the tray. On a third observation, a CNA again set up the tray on a bedside table and left; later the resident asked the surveyor for help peeling a banana, and the CNA then found the wrist weight in the resident’s bathroom and put it on the resident. Record review showed the physician’s order and the Kardex both directed 1:1 supervision with meals, use of wrist weights for all meals, and use of a sturdy table. The speech therapy discharge summary stated the resident required close supervision with intake due to inability to independently recall and carry over safety strategies. CNA documentation for December 2025 and January 2026 showed that most documented breakfast occurrences were recorded as set-up assistance only rather than supervision. During interviews, the nurse, unit manager, and DON each acknowledged that 1:1 supervision means being with the resident while eating and that the resident’s care plan should have been followed, including use of the wrist weights.
Inaccurate Oxygen Flow Rate Documentation
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident by inaccurately documenting and transcribing the resident’s supplemental oxygen flow rate. The resident was admitted with diagnoses including asthma, morbid obesity, acute and chronic respiratory failure, chronic pulmonary edema, and chronic diastolic heart failure, and the most recent MDS indicated intact cognition and that the resident received oxygen therapy. Facility policy required verification of a physician’s order for oxygen administration, but the resident’s record showed conflicting oxygen orders and documentation. Observation and record review showed the resident was receiving oxygen via nasal cannula with the concentrator set between 4 and 4.5 liters, while the MAR for January 2026 documented oxygen at 2 liters per minute. The resident’s discontinued orders showed oxygen at 4 L/min was discontinued on 11/24/25, and after a hospital return on 11/28/25, a physician’s order listed oxygen at 2 L/min. A nursing note on 12/10/25 documented the resident was saturating at 72% on 2 L and the nurse increased oxygen to 4 L, with on-call directing 4 L overnight. During interviews, the nurse, respiratory therapist, and DON stated the resident had been receiving 4 liters and that the 2-liter order was incorrect, yet staff had continued signing off that the resident received 2 liters.
Failure to Implement Ambulation Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that staff consistently implemented and followed interventions related to ambulation for a resident who required staff assistance. The resident, who had diagnoses including chronic kidney disease, anemia, depression, anxiety, and insomnia, was assessed to need partial to moderate assistance with ambulation. However, on a specific day, a CNA observed the resident ambulating independently and did not provide the required supervision or assistance as outlined in the care plan. Consequently, the resident fell, sustained a laceration on the left eyebrow, and required hospital treatment. Interviews revealed that the CNA was familiar with the resident but had not reviewed the resident's Kardex, which indicated the need for assistance with ambulation. The CNA mistakenly believed the resident was independent with just supervision. During the incident, the CNA was unable to leave other residents unsupervised and called out to a nurse for assistance, but received no response. The Unit Manager and other nursing staff were either unaware of the resident's ambulation needs or were not present at the time of the fall. The Director of Nurses confirmed that the care plan required staff assistance for ambulation, which was not followed, leading to the resident's fall and injury.
Failure to Provide Adequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance to a resident assessed as being at risk for falls, resulting in an incident where the resident sustained an injury. The resident, who had diagnoses including chronic kidney disease, anemia, depression, anxiety, and insomnia, was identified as requiring partial to moderate assistance with ambulation. Despite this, on the day of the incident, a Certified Nurse Aide (CNA) observed the resident ambulating alone but did not provide assistance or seek help from another staff member. The resident subsequently fell, sustaining a laceration that required hospital treatment. Interviews with staff revealed that the CNA was aware of the resident's need for supervision but was unable to assist due to other responsibilities. The CNA attempted to alert a nurse, who did not respond, and the resident was left unsupervised. The Unit Manager and the resident's usual nurse were not present at the time of the fall, and another nurse on duty did not hear the CNA's call for assistance. The Director of Nurses confirmed that the resident required assistance from one staff member for ambulation, highlighting a failure in staff communication and supervision that led to the resident's fall and subsequent injury.
Failure to Protect Residents from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a certified nursing assistant (CNA) who was accused of rough handling by a resident. Resident #95, who was cognitively intact, reported that CNA #5 did not follow their preferences during a transfer and was rough, causing discomfort. Despite the resident's report, the facility administrator categorized the incident as a customer service issue rather than potential abuse, and no immediate action was taken to prevent the CNA from continuing to work with residents. Subsequently, Resident #1, also cognitively intact, reported an incident involving the same CNA. The resident stated that CNA #5 forcefully pulled a laptop case handle from their arm, causing significant pain, and was rough during care. An x-ray later revealed a fracture in the resident's arm. The facility's documentation showed that the CNA was not suspended until six days after the incident, indicating a delay in addressing the potential abuse. The facility's policies on abuse prevention and investigation were not adequately followed, as the CNA continued to work without restriction after the initial grievance was filed. The lack of immediate action and thorough investigation contributed to the subsequent incident involving Resident #1, highlighting deficiencies in the facility's response to allegations of abuse.
Failure to Investigate Alleged Abuse Leads to Further Incident
Penalty
Summary
The facility failed to investigate an allegation of potential abuse involving a resident who reported being roughly handled by a certified nursing aide (CNA). The resident, who had intact cognition and required assistance with daily activities, reported the incident to the Unit Manager, expressing that the CNA did not follow transfer preferences and was rough during the process. The resident also mentioned being pressured to use an incorrect size brief. Despite the resident's report, the facility did not thoroughly investigate the incident, as evidenced by the lack of documentation in the medical record and the absence of a written statement from the involved CNA or other staff present at the time. The administrator categorized the incident as a customer service issue rather than potential abuse, based on her interpretation of the resident's report. The Director of Nursing also inquired if the resident felt the actions were malicious, to which the resident responded negatively. However, the facility's policy requires all allegations of abuse to be thoroughly investigated, including interviews with all relevant parties and documentation of findings, which was not adequately followed in this case. As a result of the inadequate investigation, the accused CNA continued to work and subsequently was involved in another incident with a different resident. This resident reported being roughly handled by the same CNA, resulting in pain and a fracture in the arm. The facility eventually suspended and terminated the CNA, but the failure to initially investigate the first allegation allowed the CNA to continue working and potentially harm another resident.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to meet professional standards of practice for four residents, leading to deficiencies in care. For one resident, the facility did not implement physician-ordered compression stockings, which were intended to manage lower extremity edema. Despite documentation indicating that the stockings were applied, observations revealed that the resident was not wearing them, and they were found in a dresser drawer. Interviews with nursing staff confirmed that the stockings were not applied as ordered. Another resident experienced issues with enteral nutrition management. The facility failed to clarify conflicting physician orders for g-tube flushes, resulting in incorrect settings on the feeding tube pump. The resident's care plan and physician orders indicated specific flush volumes and schedules, but the pump was set incorrectly, and the orders were not clarified, leading to potential discrepancies in fluid administration. Additionally, a resident was placed on a mechanical soft diet without a recent evaluation by speech therapy, despite the resident's request for a regular diet and a hospital discharge summary indicating a regular diet. The facility's process for notifying the therapy department of diet recommendations was not followed, resulting in a lack of evaluation. Lastly, the facility did not obtain weekly weights for a resident as ordered, missing several scheduled weigh-ins, which were crucial for monitoring the resident's nutritional status given their medical history of weight loss and malnutrition.
Insufficient Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly on weekends, as evidenced by the payroll-based journal (PBJ) report submitted to CMS for Fiscal Year Quarter 4, 2024. The PBJ Staffing Data Report indicated that the facility's weekend staffing levels were excessively low, triggering a concern that required follow-up during the survey. The facility's 'Facility Assessment Tool' outlined a staffing plan requiring 15 licensed nurses and 30 nurse aides, with a total of 3.20 hours per patient day (HPPD) for direct care staff. However, the facility only met this required HPPD in one out of the 12 weeks during the specified quarter. The Administrator acknowledged the difficulty in recruiting staff last year, although they have since managed to staff appropriately using on-call nursing management when necessary.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and dated once opened according to the manufacturer's guidelines. During observations, it was noted that several medications on two different medication carts were open and undated, making it impossible to determine their expiration dates. These included saline nasal spray, Risperidone Oral Solution, Fluticasone-salmeterol, and fluticasone nasal spray, among others. Interviews with nursing staff and the Director of Nursing confirmed that medications should be dated when opened and discarded according to the manufacturer's instructions. Additionally, a bottle of Tuberculin Purified Protein Derivative was found open, dated, and unrefrigerated, contrary to the manufacturer's storage instructions. The facility also failed to ensure that medications were stored in locked compartments. A medication cart on the Dementia Unit was observed to be unlocked and accessible without any staff present. This was confirmed by Nurse #1, who acknowledged that the cart should have been locked when unattended. These deficiencies highlight lapses in medication management and storage protocols within the facility.
Failure to Schedule Specialist Appointments for Cataract Surgery
Penalty
Summary
The facility failed to ensure that recommended specialist appointments were scheduled for three residents who had recommendations for an evaluation for cataract surgery from the consulting eye doctor. The facility's policy allows for the use of outside resources to furnish specific services to residents, but this was not followed in the cases of Residents #32, #28, and #93. Each of these residents had been recommended for cataract surgery by a consulting eye doctor, but the facility did not schedule the necessary follow-up appointments. Resident #32, admitted in December 2021, has moderate cognitive impairment and uses corrective lenses. Despite a recommendation for cataract surgery in April 2024, no follow-up was scheduled, and the resident expressed frustration over worsening vision. The resident's health care proxy was unaware of the need for a consult, and the outpatient eye doctor's office confirmed no referrals had been received. Similarly, Resident #28, who is cognitively intact, was recommended for cataract surgery in December 2024, but no follow-up was scheduled. The resident expressed difficulty in watching television and reading due to vision issues, and the outpatient office confirmed no referrals were made. Resident #93, with moderate cognitive impairment, was also recommended for cataract surgery in December 2024, but no follow-up was scheduled. The unit manager was unaware of the recommendations, and the outpatient office confirmed no referrals were received. The Director of Nurses stated that recommendations from consulting providers should be followed up within a week, but this was not done for any of the three residents, indicating a failure in the facility's process for managing specialist referrals.
Documentation and Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for four residents, leading to several deficiencies. For one resident, the Treatment Administration Record (TAR) inaccurately documented that oxygen was running at the correct setting, that the oxygen tubing was changed as ordered, and that foam ear protectors were in place. Observations revealed that the oxygen was set at a higher level than prescribed, the tubing was not changed as documented, and foam ear protectors were not in place. Interviews with staff confirmed these discrepancies, indicating a lack of adherence to the facility's oxygen administration policy. Another resident's antipsychotic medication order lacked an associated diagnosis, contrary to the facility's policy on psychotropic medication use. The resident was receiving risperidone without a documented medical diagnosis related to its administration. Interviews with the unit manager and the Director of Nursing confirmed that the medication order should have included an associated diagnosis, highlighting a failure in medication management and documentation. Additionally, a resident with diabetes did not receive their insulin as documented in the Medication Administration Record (MAR). The nurse documented the insulin as administered at a specific time, but observations and interviews revealed that the insulin was given much later, after the resident had already eaten breakfast. This discrepancy in medication administration timing was acknowledged by the nurse and the Director of Nursing. Furthermore, another resident's blood pressure was documented as taken from the wrong arm, despite physician orders specifying the correct arm due to a dialysis shunt. The Director of Nursing suggested that the documentation error was likely due to incorrect data entry, as the resident was cognitively intact and would have advocated for themselves.
Failure to Investigate Abuse Allegations Leads to Further Resident Harm
Penalty
Summary
The facility failed to implement its abuse policy by not investigating an allegation of abuse from Resident #95, which subsequently led to the abuse of another resident by the same certified nursing aide (CNA). Resident #95, who was admitted with diagnoses including hypertension and osteoporosis, reported that a CNA handled him/her roughly during a transfer and did not provide the correct sized brief. The resident felt coerced into using a smaller brief due to the CNA's behavior. Despite the resident's report, the facility treated the incident as a grievance rather than an abuse allegation, and no thorough investigation was conducted. The facility's policy requires all allegations of abuse to be thoroughly investigated and reported to the appropriate agencies. However, the administrator categorized the incident as a customer service issue, believing it was not malicious. The administrator and Director of Nursing did not follow up adequately with Resident #95, and the incident was not documented in the medical record or reported to the state agency as required. Subsequently, another resident, Resident #1, reported being physically abused by the same CNA. The resident experienced pain and a fracture in the left ulna after the CNA forcefully pulled a laptop case handle from the resident's arm. The CNA also exhibited inappropriate behavior by refusing to assist the resident with a drink and making derogatory comments. The facility eventually suspended and terminated the CNA, but the initial failure to investigate the first allegation allowed the CNA to continue working and led to further abuse.
Failure to Report Alleged Rough Handling by CNA
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a resident who reported rough handling by a certified nursing aide (CNA). The resident, who was admitted with diagnoses including hypertension and osteoporosis, reported to another staff member that the CNA did not follow their preferences for transferring and pulled their arm too hard during a transfer. The resident expressed feeling safe but wanted the CNA to be trained on their transfer preferences. Despite the resident's report, the incident was not documented in the medical record or reported to the appropriate authorities as required by the facility's policy. During interviews, the resident recalled the incident, stating that the CNA was rough during a transfer to the toilet and did not provide the correct size brief, which led to the resident feeling coerced into using an inappropriate size. The administrator and the Director of Nursing (DON) both interviewed the resident, who indicated that the actions were not malicious. The administrator categorized the incident as a customer service issue rather than potential abuse, leading to the failure to report the incident to the state licensing/certification agency. The facility's policy requires immediate reporting of such allegations, but this protocol was not followed in this case.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to implement an individualized, comprehensive care plan for a resident, specifically neglecting to use fall mats as an intervention for fall prevention. The resident, admitted with diagnoses including metabolic encephalopathy, falls, anxiety, and atrial fibrillation, was assessed to have moderate cognitive impairment and required assistance with activities of daily living. Despite the care plan indicating the need for fall mats on both sides of the bed, the resident experienced multiple falls over a period of time, with incidents recorded on several dates. Observations by the surveyor confirmed the absence of fall mats, and interviews with staff revealed a lack of awareness and implementation of this intervention. The resident's care plan, dated 11/27/24, included the use of fall mats as a preventive measure, yet the resident continued to fall, sustaining injuries such as skin tears. Interviews with the CNA, nurse, and unit manager highlighted a disconnect between the care plan and its execution, as staff were either unaware of the requirement or unable to locate the fall mats. The Director of Nursing acknowledged the resident's cognitive impairment and high risk for falls, emphasizing the necessity of implementing the care plan. This deficiency in care planning and execution was identified through observations, record reviews, and staff interviews, underscoring the facility's failure to meet the resident's needs as outlined in their care plan.
Failure to Monitor Resident's Weight Due to Broken Scale
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with congestive heart failure. The resident, who was admitted with diagnoses including chronic diastolic heart failure and generalized edema, had physician orders for daily weight monitoring to manage potential fluid buildup. However, the facility did not obtain the resident's daily weights for three consecutive days, resulting in a significant weight gain of 5.2 pounds over this period. The failure to obtain daily weights was attributed to a broken scale, which was not addressed promptly. Interviews with nursing staff revealed that the scale had been malfunctioning for some time, and there was a lack of awareness among staff and management about the issue. Despite the availability of other scales in the facility, the staff did not utilize them to fulfill the physician's orders. This oversight was not communicated effectively to the unit manager or the Director of Nursing, who were unaware of the scale's condition until after the deficiency was noted.
Failure to Obtain Physician's Order for Air Mattress Settings
Penalty
Summary
The facility failed to provide care consistent with professional standards for a resident with pressure ulcers, specifically by not obtaining a physician's order for the appropriate settings of an air mattress in use. The resident, who was admitted with diagnoses including heart failure and hypotension, was observed on multiple occasions lying on an air mattress set at 175 pounds, despite their recorded weight being 148.7 pounds. The resident's care plan indicated the use of a low air loss mattress but did not specify the appropriate settings, and there was no physician's order for the air mattress settings in the resident's active orders. Interviews with facility staff, including a nurse, unit manager, and the Director of Nurses, revealed that air mattresses should be set according to the resident's weight to prevent skin breakdown. However, the resident did not have a physician's order specifying the settings, which is necessary for staff to monitor and ensure the correct settings are maintained. The resident had two unstageable deep tissue injuries, one on the heel and one on the coccyx, which were present on admission, highlighting the importance of proper mattress settings to promote healing and prevent further skin breakdown.
Failure to Maintain PICC Line Care
Penalty
Summary
The facility failed to provide proper care and maintenance of a Peripherally Inserted Central Catheter (PICC) for a resident, leading to a deficiency in the administration of intravenous therapy. Specifically, the facility did not change the PICC line dressing as ordered by the physician and failed to obtain weekly measurements for the external length of the PICC line to ensure it had not migrated. The resident, who was admitted with multiple diagnoses including metabolic encephalopathy and atrial fibrillation, had a PICC line dressing that was last changed on 1/2/25, despite the requirement for it to be changed every 7 days. The deficiency was observed when a surveyor noted the outdated dressing on 1/14/25. Interviews with staff revealed that Nurse #3, a Licensed Practical Nurse, was not trained to change PICC line dressings and mistakenly believed that only Registered Nurses could perform this task. The Unit Manager confirmed that the dressing should have been changed and measurements taken, but these actions were not completed. The Director of Nursing acknowledged the requirement for dressing changes and measurements every 7 days, which were not adhered to in this case.
Failure to Adhere to Physician's Orders for Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards for a resident diagnosed with Acute Respiratory Failure with Hypoxia and shortness of breath. The resident was ordered by a physician to receive oxygen at 2L per minute via nasal cannula, with the oxygen saturation maintained above 90%. Additionally, the physician ordered the oxygen tubing to be changed weekly and foam ear protectors to be applied to the nasal cannula tubing. However, observations revealed that the resident was receiving oxygen at 3L per minute, the oxygen tubing was not changed as per the schedule, and foam ear protectors were not in place. The facility's documentation inaccurately indicated compliance with the physician's orders, noting that the oxygen was running at 2L, the tubing was changed on specified dates, and foam ear protectors were in place. However, direct observations contradicted these records, showing the resident with incorrect oxygen settings and missing foam ear protectors. Interviews with staff, including a CNA and the Unit Manager, confirmed the discrepancies, with the Unit Manager acknowledging the oversight in changing the tubing and setting the correct oxygen level. The Director of Nursing also confirmed the expectation for adherence to the physician's orders, which was not met in this case.
Deficiency in Trauma-Informed Care Planning
Penalty
Summary
The facility failed to develop a care plan for Trauma Informed Care or Post Traumatic Stress Disorder (PTSD) with resident-specific triggers and interventions for two residents. Resident #7, admitted in May 2023, had diagnoses including PTSD, depression, and anxiety. Despite having an intact cognition score of 15 out of 15 on the Minimum Data Set (MDS) assessment, the facility's Social Services Assessment inaccurately indicated that Resident #7 did not experience past trauma. The active care plan for Resident #7 included general interventions but lacked specific triggers or interventions tailored to the resident's PTSD. Resident #85, admitted in February 2024, had diagnoses including PTSD, dementia, and depression, with a severe cognitive impairment score of 6 out of 15 on the MDS assessment. The care plan for Resident #85 also lacked specific triggers or interventions, with a blank focus for PTSD. During interviews, the Social Worker acknowledged inaccuracies in the assessments and the Director of Nursing expressed expectations for resident-specific care plans, highlighting the deficiency in providing trauma-informed care tailored to the residents' needs.
Failure to Provide Dental Care for a Resident
Penalty
Summary
The facility failed to provide dental care for a resident, identified as Resident #71, who was admitted in May 2024 with diagnoses including Parkinson's Disease, malnutrition, and depression. Despite the facility's policy indicating that dental services are available for all residents requiring routine and emergency dental care, Resident #71 reported not having seen a dentist since admission. The resident expressed a desire to see a dentist to help with chewing but stated that they had not been asked if they wanted dental services. An observation by the surveyor revealed multiple missing teeth and obvious carious teeth with dark discoloration. The facility's documentation, including the Admission/Readmission Screener and the active care plan, noted missing teeth but failed to indicate the presence of carious teeth. The care plan included an intervention to coordinate arrangements for dental care, yet there was no record of the resident being seen by a dentist or being asked about dental care. During an interview, the Director of Nursing acknowledged that the resident should have had a dental consult, highlighting the facility's failure to adhere to its policy and provide necessary dental care.
Failure to Follow Up on Dental Care Recommendations
Penalty
Summary
The facility failed to provide necessary dental services for a resident who was recommended for tooth extractions and new dentures by a consulting dentist. The resident, who has moderate cognitive impairment, was seen by a dentist in May 2024, who recommended the extraction of non-restorable teeth and the fabrication of dentures. However, there was no follow-up on these recommendations, and the resident did not receive the necessary dental care. The resident expressed concerns about missing teeth and the lack of dentures, which affected their ability to chew properly. The medical record review revealed that there were no nursing notes or follow-up information related to the dentist's recommendations. Consent forms for tooth extraction were not signed, and no appointments were scheduled with an oral surgeon. Interviews with nursing staff and the unit manager confirmed that they were unaware of the resident's need for extractions and dentures, and the process was not documented or communicated within the clinical team. The Director of Nursing acknowledged the lack of documentation and follow-up, indicating a failure in the facility's responsibility to ensure dental recommendations were reviewed and acted upon.
Failure to Implement QAPI Plan After Abuse Allegations
Penalty
Summary
The facility failed to develop a Quality Assurance Performance Improvement (QAPI) plan following two allegations of abuse against the same certified nursing aide (CNA). Two residents reported abuse by CNA #5, with one grievance filed alleging rough handling and another incident report indicating abuse. Despite these allegations, the facility did not establish a QAPI plan to address and prevent further quality of care issues, nor did it ensure the safety of residents. The facility's policy requires the identification, investigation, and reporting of all possible incidents of abuse, neglect, or mistreatment, and mandates the implementation of a QAPI review and analysis of such reports. The Administrator terminated CNA #5 for reasons related to customer service and insubordination, citing the CNA's body language and attitude. However, the Administrator did not recall specific phrases that led to the termination. Although the Administrator claimed to have developed a QAPI plan after the alleged abuse incident, the plan was found to be incomplete, with no further audits or plans to ensure resident safety implemented. The Administrator was unable to produce evidence of resident safety interviews during the survey, and the QAPI plan provided was blank and incomplete, with a target date set prior to the initial incident.
Failure to Implement Contact Precautions for Infected Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of implementation of contact precautions for two residents diagnosed with communicable infections. Resident #111, who was admitted with multiple diagnoses including pneumonia and chronic kidney disease, tested positive for Clostridium difficile (C. difficile). Despite the presence of a contact precaution sign on the resident's door, staff members were observed entering and exiting the room without wearing personal protective equipment (PPE) and without performing proper hand hygiene. This included instances where staff members handled items and interacted with other residents without adhering to the necessary infection control protocols. Similarly, Resident #2i, who was admitted with conditions such as phantom limb syndrome and morbid obesity, was diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the elbow. The resident's care plan indicated the need for enhanced barrier precautions, yet there was no signage or PPE cart outside the resident's room to indicate the required contact precautions. The infection preventionist was unaware of the resident's MRSA status, and the necessary precautions were not implemented, leaving the resident and others at risk of infection transmission. Interviews with the Director of Nursing (DON), the Administrator, and other staff members revealed a lack of adherence to infection control guidelines. The DON acknowledged that contact precautions should have been in place for both residents, and staff were expected to follow infection control protocols. However, observations indicated a systemic failure to implement these precautions, as staff continued to neglect the use of PPE and proper hand hygiene, thereby compromising the facility's infection control efforts.
Failure to Offer COVID-19 Vaccine During New Hire Orientation
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to two employees during their new hire orientation, which was a requirement according to the facility's policy. The policy, titled 'Employee Infection and Vaccination Status,' mandates that employees be assessed for vaccination status against infectious conditions prior to or upon their duty assignment. It also requires that employees be current with mandated vaccinations before performing direct resident care. Despite these requirements, the facility did not offer the COVID-19 vaccine to Nurse #3 and Activities Assistant #1 during their orientation sessions. The Director of Nurses confirmed that both employees were provided with informed consent forms and educated on the COVID-19 vaccination side effects, but they refused the vaccination. However, the forms were not properly completed, as Nurse #3 did not date the form. The Human Resources Manager confirmed the dates of the new hire orientations for both employees, indicating that the oversight occurred during these sessions. The Administrator acknowledged that both employees have been working in the facility since their orientation, highlighting the lapse in following the facility's vaccination policy during the onboarding process.
Inaccurate MDS Coding for Dental and Feeding Tube Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident #71, who was admitted with diagnoses including Parkinson's, malnutrition, and depression, was inaccurately coded on the MDS regarding dental status. Despite having multiple missing and carious teeth, the MDS indicated no obvious broken or carious teeth. This discrepancy was confirmed during an interview with the resident, who expressed a desire to see a dentist to help with chewing, and was further corroborated by the Director of Nursing, who acknowledged the MDS should reflect the resident's actual dental condition. For Resident #47, who was admitted with conditions such as chronic obstructive pulmonary disease, tracheostomy status, paranoid schizophrenia, anxiety, and dysphagia, the MDS failed to code the presence of a feeding tube. The resident's plan of care included enteral tube feeding, yet the MDS inaccurately indicated no feeding tube was present. This error was acknowledged by the MDS Nurse and the Director of Nursing, who stated that the MDS should be coded according to the Resident Assessment Instrument (RAI) manual.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Haverhill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oxford Rehabilitation & Health Care Center | 0.4 mi | ★★★★★ | 21 | 0 |
| Lakeview House Skld Nrsg And Residential Care Fac | 1.6 mi | ★★★★★ | 0 | 0 |
| Haverhill Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 8 | 0 |
| Penacook Place, Inc | 1.9 mi | ★★★★★ | 2 | 0 |
| Baker-katz Skilled Nursing And Rehabilitation Ctr | 2.4 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.