Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Oc Reading Center Llc during CMS and state inspections, most recent first.
Dignified Existence Not Maintained: Staff were observed using personal cell phones in resident areas, including a dining room and a resident room where a resident was on 1:1 observation. Staff were also heard speaking a language other than English in front of residents, including in a resident room and near an occupied room, while the DON stated this was not appropriate around residents.
Medication storage and labeling failures were observed on three medication carts. Opened insulin vials and pens, inhalers, and other medications were left undated despite manufacturer instructions for beyond-use dating, and some items requiring refrigeration, including acidophilus capsules and liquid lorazepam, were not stored as directed. Nurses and the DON stated that medications should be labeled, dated, and discarded according to manufacturer guidelines.
Failure to assess pillows used to keep a resident in bed as a potential restraint. A resident with Parkinson's disease, diabetes, malnutrition, and severe cognitive impairment was observed multiple times in bed on a perimeter mattress with pillows tucked under the fitted sheet and on top of the mattress edges on both sides. Staff said the pillows were used to keep the resident in bed because the resident falls out of bed, but the record lacked documentation supporting their use as a restraint.
Failure to Develop Baseline Falls Care Plan Within 48 Hours: A resident admitted after a fall with LOC and severe cognitive impairment had falls identified on admission assessments, but the baseline person-centered falls care plan was not implemented until several days after admission. The resident had a history of repeated falls, unsteadiness, obesity, and chronic Afib not on AC due to recurrent falls, and staff confirmed the care plan should have been created within 48 hours because the resident was admitted due to a fall.
Missed Weekly Skin Checks and Wound Documentation for a Resident With a Stage 2 Heel Ulcer: A resident with peripheral vascular disease, prior CVA, and vascular dementia had a non-admission pressure ulcer on the right heel. Although orders required weekly skin checks and the care plan called for weekly skin monitoring and wound assessment, only 11 of 35 weekly skin checks were documented over several months, and the last wound assessment showed a 2.5 cm by 2.5 cm stage 2 ulcer with moderate drainage, non-granulating tissue, purple discoloration, slough, and necrotic tissue. Staff stated they were unaware the weekly documentation had not been completed.
Failure to Address Significant Weight Loss: A resident with cognitive impairment, weakness, and a history of falls experienced rapid, ongoing weight loss after admission, dropping from 232.2 pounds to 204.4 pounds and then to 198.8 pounds. The record did not show timely reweighs, RD review, or provider notification when the loss first became significant, and the care plan interventions were not updated until months later. Staff interviews confirmed the loss should have been addressed sooner.
A resident with ESRD and a right tunneled femoral hemodialysis line did not have the ordered bedside clamp available. Surveyors observed a gauze bag above the bed but no clamp, and the UM and DON confirmed the clamp should have been kept at the bedside per the MD order for emergency use if the line broke.
A resident who was cognitively intact and dependent on staff for care reported being roughly handled, spoken to in a rude and disrespectful manner, and laughed at by a CNA during overnight care. The resident's account was consistent across multiple interviews and was substantiated by the facility's internal investigation, which found that the care provided did not meet the required standards of dignity and respect.
A resident on Full Code status with COPD, CHF, pulmonary HTN, Afib, and OSA was found unresponsive after not wearing BiPAP. Staff initiated CPR, but interviews showed confusion and inconsistency in the response: the LPN left briefly to get help, the AED was not applied, a CNA did not bring the AED and did not know where it was located, and another nurse provided bag-mask ventilation while CPR continued until EMS arrived. The resident was later pronounced dead at the facility, and the investigation noted respiratory failure with contributing nonadherence to BiPAP.
Nurses and nurse aides lacked the necessary competencies to provide care that maximized the well-being of each resident, resulting in care that did not meet individualized needs.
A resident with a history of suicidal ideation and depression was not provided with appropriate behavioral health services at the facility. Despite recommendations for psychiatric consults and medication management, the facility failed to implement a care plan or make necessary referrals for psychotherapy. The resident attempted suicide at the facility, and upon readmission, the plan of care was not updated. Interviews revealed a lack of communication and follow-up by facility staff regarding the resident's mental health needs.
A facility failed to provide appropriate treatment for a resident with a history of depression and suicidal ideation. Despite recommendations for psychiatric consults and medication management, the facility did not develop or update a care plan addressing the resident's needs. The resident expressed active suicidal ideation and attempted suicide, yet the facility did not implement necessary interventions or communicate treatment plans effectively. Staff interviews revealed a lack of awareness and communication regarding the resident's history and needs.
The facility failed to develop comprehensive care plans for two residents, one with suicidal ideation and another with incontinence. The resident with SI did not have a care plan addressing their condition, leading to a suicide attempt. The other resident lacked a care plan for incontinence, resulting in inadequate care and dissatisfaction. Staff were unaware of these issues, and the facility did not follow its policies for care planning.
A resident at high risk for pressure ulcers did not receive necessary interventions, leading to the reopening of a previously healed ulcer. The facility failed to offload the resident's heels and maintain correct air mattress settings. Additionally, wound care orders for a new ulcer were not obtained, and weekly assessments of a deep tissue injury were not conducted. Documentation of weekly skin assessments was also inconsistent.
The facility failed to ensure nursing staff were trained and competent in wound care, leading to multiple deficiencies such as not implementing pressure ulcer prevention, failing to assess wounds weekly, and not performing hand hygiene during wound care. None of the three nurses reviewed had completed wound care competencies in the past year, partly due to the absence of a staff development nurse.
A resident in a LTC facility, who was cognitively intact and always incontinent, repeatedly had to eat breakfast while sitting in a soiled brief. Despite the resident's requests for incontinence care before meals, staff did not provide assistance, citing mealtime as a reason. The facility's policy on dignity and quality of life was not followed, and the resident's medical record lacked a care plan for incontinence.
The facility failed to notify the physician and obtain wound care orders for two residents with significant skin conditions. One resident had a pressure ulcer and a skin tear, while another had pressure wounds on the buttocks. Despite facility policy, the provider was not informed, and no treatment orders were obtained, leading to deficiencies in care.
A resident repeatedly complained about staff sleeping during night shifts, but the facility failed to document or address these grievances according to its policy. Despite the resident's efforts, including providing photographic evidence, the issue persisted, with other residents also reporting similar observations. Interviews revealed inconsistencies in grievance documentation, and the DON acknowledged awareness of the issue but lacked documentation of any investigations.
A resident with severe cognitive impairment and mobility issues was involved in an alleged abuse incident during an incorrect transfer by a nurse. The facility failed to update the resident's care plan and did not document follow-up by the Social Worker, as required by their abuse policy. The DON admitted to not updating the care plan and was unsure about the Social Worker's follow-up.
The facility failed to investigate allegations of neglect for two residents. One resident, dependent on staff for toileting, reported being told they would be changed later, with no proper investigation documented. Another resident, requiring substantial assistance, was left in a chair for nine hours despite requests to be put back to bed. The DON acknowledged these grievances but did not provide investigation documentation, viewing them as customer service issues.
The facility failed to meet professional standards for two residents by not implementing physician orders for wound care and heel protection. One resident did not receive daily wound dressings as ordered, and another was observed without heel protection booties despite physician orders. Staff interviews confirmed the orders were not followed, and there was no documentation of refusal by the residents.
The facility failed to provide scheduled weekly showers to three residents, despite their dependency on staff for bathing due to medical conditions like acute and chronic respiratory failure, cerebral palsy, and muscle weakness. Residents reported not receiving showers for extended periods, and documentation confirmed the lack of showers, with no records of refusals. The DON was aware of the issue but believed it was resolved, yet no refusals were documented.
A resident experienced a delay in obtaining hearing aids due to the facility's failure to timely implement ear wax removal, as recommended by an audiologist. Despite the resident's intact cognition and minimal hearing difficulty, the treatment was delayed for nearly nine months, affecting the resident's access to necessary hearing services.
The facility failed to update care plans or conduct falls assessments for two residents after falls, resulting in deficiencies in care. One resident experienced multiple falls, including one with a fracture, without care plan revisions. Another resident had a fall resulting in a fracture, but their care plan was not updated. The facility's fall reduction policy was not followed, indicating a deficiency in managing fall risks and care plan updates.
A facility failed to ensure proper communication and monitoring for a resident requiring dialysis. The resident's dialysis communication book often lacked post-dialysis weights, and staff did not consistently follow up on missing information. Interviews revealed a lack of communication with the dialysis center and confusion about the facility's responsibility in managing the resident's dialysis care.
A facility failed to review and address pharmacy recommendations for a resident with severe cognitive impairment. The pharmacist recommended evaluating the need for Enoxaparin and adjusting the timing of Atorvastatin. These recommendations were not communicated to the physician due to the Nurse Unit Manager's absence, resulting in a delay in implementation.
A facility failed to maintain a medication error rate below 5%, with a nurse making two errors out of 31 opportunities. A resident received incorrect calcium carbonate and ferrous sulfate without dosage clarification. The nurse was unaware of the need to clarify orders, and the correct type of calcium carbonate was unavailable. The resident had severe cognitive impairment and was admitted with diabetes and hypertension.
The facility failed to store medications in their original, labeled containers, as observed by a surveyor and a nurse who found unlabeled pills in medication cups on a cart. A nurse admitted to pouring the medications earlier but not administering them due to resident unavailability, intending to do so later. The DON confirmed that medications should not be stored in this manner and should be discarded if not administered.
The facility failed to maintain accurate medical records and complete daily documentation for three residents. A resident with diabetes and venous ulcers had wound care documented as completed when it was not, with no record of refusal or rationale. Additionally, two residents had incomplete documentation of bathing tasks over three months, despite requiring assistance. Interviews confirmed significant missing documentation, which the DON acknowledged.
The facility did not develop a QAPI plan to address residents' concerns about not receiving showers. Resident Council minutes from several meetings indicated that showers were not happening as scheduled. During a Resident Group meeting, most participants reported not having had a shower in a long time. The DON was unaware of the issue because the Activities Director had not shared the meeting minutes, preventing the issue from being addressed in the QAPI process.
A nurse in an LTC facility failed to follow proper hand hygiene protocols during wound and tracheotomy care. The nurse did not perform hand hygiene after removing gloves while treating a resident's wounds and did not change gloves after contact with tracheotomy secretions. The nurse acknowledged the oversight, and the DON confirmed the correct procedures.
The facility failed to provide written notice to residents before room changes or new roommate assignments, affecting 21 alert and oriented residents. Despite a policy requiring verbal and written notice, no documentation was found in clinical records, and interviews confirmed the lack of notice. The Administrator and DON admitted that a corporate directive led to immediate relocations without following the policy, preventing residents from being informed or discussing changes with family.
Dignified Existence Not Maintained
Penalty
Summary
The facility failed to ensure residents were provided with a dignified existence on two units when staff members used personal cell phones in resident areas with residents present. On the second-floor dining room, a CNA was observed sitting in the corner using her personal cell phone while multiple residents were in the dining room and she was not engaging with them. Later, in a resident room where the resident was on one-to-one observation, two CNAs were observed in the room with the resident lying in bed; one CNA had her personal cell phone on a bedside table and the other was standing next to her leaning over and looking at the phone. A CNA was later seen leaving the room holding the cell phone and placing it in her pocket. The DON stated staff should not be on personal cell phones in resident areas and said the behavior was unacceptable. The facility also failed to ensure staff were not speaking a foreign language to each other in front of residents who did not speak that language. In one resident room, a housekeeper and CNA were observed speaking in a language that was not English while the resident was seated in a specialized recliner between them; the conversation was between the staff members and not with the resident. The resident's MDS listed English as the preferred language and showed a Brief Interview for Mental Status score of 10 out of 15, indicating moderately impaired cognition. On the third-floor unit, two staff members were heard speaking in a language that was not English near the nursing desk and entrance to an occupied resident room, with another resident sitting in a wheelchair next to them. The DON stated staff should not speak to each other in another language around residents unless it is their preferred language.
Medication Storage and Labeling Failures on Multiple Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws and the facility’s policy requiring medications to be stored safely, securely, and properly following manufacturer recommendations. The report states that on three medication carts, staff did not label or date multiple opened medications according to manufacturer guidance, including insulin lispro vials, tirzepatide injection pen, umeclidinium inhalers, Tresiba injection pen, umeclidinium and vilanterol inhalers, insulin glargine pen, and fluticasone furoate/umeclidinium/vilanterol inhaler. Staff also left some medications out of required storage conditions, including opened acidophilus capsules that required refrigeration and opened liquid lorazepam bottles that were not refrigerated. The observations showed additional storage issues on the carts, including an unopened glargine insulin vial that required refrigeration until opened and several opened insulin vials and pens that were undated. During interviews, Nurse #1, Nurse #2, Nurse #3, and the DON stated that nursing should label and date medications based on manufacturer guidelines and that medications should be discarded according to manufacturer recommendations. The findings were observed on the second-floor front cart, second-floor back cart, and third-floor front cart.
Failure to Assess Pillows Used to Keep a Resident in Bed as a Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of pillows tucked underneath a fitted sheet and placed on top of the raised edges of a perimeter mattress as a potential physical restraint for one resident. The facility policy titled, "Restraint Free Environment," defined physical restraints as devices or materials attached or adjacent to the resident's body that the resident cannot remove easily and that restrict freedom of movement, and it specifically listed tightly tucked sheets, cushions the resident cannot remove, and concave mattresses as examples of restraints. Resident #42 was admitted in July 2025 with diagnoses including Parkinson's disease, diabetes, and malnutrition. The 9/30/25 MDS indicated severe cognitive impairment, dependence on staff for mobility, and that the resident did not utilize a restraint. The care plan related to falls, initiated 7/10/25 and revised 12/30/25, noted a perimeter mattress and to keep the resident in the center. During multiple observations on 12/29/25 and 12/30/25, the resident was seen lying in bed on a perimeter mattress with pillows tucked under the fitted sheet and on top of the mattress edges on both sides of the bed. At one point the resident was lying sideways with legs over the side of the bed while the pillows remained in place, and staff repositioned the resident without removing the pillows. CNA #3 stated the pillows were used to keep the resident in bed because the resident falls out of bed no matter what staff do. Unit Manager #2 said the pillows should not be used as they are a restraint, and the DON stated that if nursing is putting pillows under a fitted sheet, it should be assessed for a restraint and care planned, but it should not be used as it is a restraint. The clinical record, including care plans, paper chart, electronic record, assessments, and physician orders, did not include documentation supporting the use of the pillows under the fitted sheet.
Failure to Develop Baseline Falls Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement an effective baseline person-centered care plan within 48 hours of admission for one resident out of a sample of 19. Resident #76 was admitted in December 2025 with diagnoses including myocardial infarction, repeated falls, and unsteadiness on feet, and the admission BIMS showed severe cognitive impairment with a score of 0 out of 15. The resident’s admission assessments identified falls as a care area, and the fall risk assessment documented the resident’s last known fall as occurring during the current stay or within the past month. The resident had been brought to the acute care hospital after a fall with loss of consciousness and had a prior medical history including obesity and chronic atrial fibrillation not on anticoagulants due to recurrent falls. Although the facility policy required a preliminary baseline care plan within 48 hours of admission, the resident’s falls care plan with person-centered interventions was not implemented until four days after admission. Nursing notes also documented that the resident was admitted status post fall, and staff interviews confirmed that the baseline falls care plan should have been created within 48 hours because the resident was admitted due to a fall.
Missed Weekly Skin Checks and Incomplete Wound Documentation for a Resident With a Stage 2 Heel Pressure Ulcer
Penalty
Summary
The facility failed to ensure a resident with a stage 2 pressure ulcer received necessary care and services to promote healing, prevent infection, and prevent new ulcers from developing. The resident was admitted in April 2025 with peripheral vascular disease, a history of cerebral infarction, and vascular dementia, and the MDS dated 11/26/25 indicated severe cognitive impairment with a BIMS score of 7 out of 15. The MDS also indicated the resident had a pressure ulcer that was not present on admission. The resident’s active orders included weekly skin checks on Thursdays, and the plan of care directed staff to monitor skin during care and weekly during skin assessments. The Norton Scale dated 5/20/25 identified the resident as moderate risk for pressure ulcer development with a score of 11. Review of the skin checks from May 2025 through December 2025 showed only 11 weekly skin checks completed out of 35 documented weekly opportunities. Review of the wound record showed the last wound assessment was completed on 10/23/25, when the right heel stage 2 pressure ulcer measured 2.50 cm by 2.50 cm with no depth and moderate serosanguineous drainage. The wound care specialist’s note from that date stated the heel scab had been mechanically debrided and the wound bed showed non-granulating tissue with areas of purple discoloration, suggestive of early ischemic changes or persistent deep tissue involvement. The weekly observation tool from that date indicated the wound was worsening and had slough and necrotic tissue present, but the medical record did not contain further documentation describing the right heel pressure ulcer. During interviews, the Unit Managers stated they were not aware weekly documentation had not been completed, and the DON stated weekly skin checks and weekly wound assessments should be completed and documented.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure professional nutrition standards were implemented for one resident with a history of pain in the left hip, difficulty walking, cognitive impairment, muscle weakness, and falls. The resident was admitted in May 2025, had a BMI of 33.3 on admission, and was documented as needing setup or clean-up assistance for eating. The facility policy required weights to be monitored for unintended loss, with any 5% or greater change retaken the next day and the dietitian notified in writing if verified. The resident’s weights showed a rapid decline from 232.2 pounds on admission to 215.6 pounds, then to 204.4 pounds and 198.8 pounds. The documented loss from 215.6 pounds to 204.4 pounds represented 11.97% body weight loss in about 60 days, which met the facility’s criteria for severe weight loss. The record did not show a reweigh after the 6/4/25 loss or after the further loss documented on 7/14/25, and progress notes from 5/15/25 through 7/13/25 did not document the weight loss or notification of the RD or medical provider. The resident was not assessed by an RD until 9/23/25. The care plan, initiated on 5/16/25 and revised on 9/23/25, identified the resident as at risk for malnutrition related to elevated BMI and past medical history, but the interventions were not revised until more than 4 months after admission and more than 3 months after the significant weight loss was documented. A progress note on 7/14/25 stated the NP was made aware of the weight loss and no new orders were given, and weekly weights were not ordered until 7/21/25. During interviews, staff stated that weight loss should be rechecked and reported, and the DON acknowledged the resident’s weight loss was unexpected and should have been addressed when it was first documented.
Missing bedside clamp for hemodialysis line
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident with end-stage renal disease and dependence on renal dialysis. Resident #17 was admitted with diagnoses including end stage renal disease, diabetes, and atrial fibrillation, and the most recent MDS indicated the resident was cognitively intact, independent with activities of daily living, and required dialysis. The resident’s care plan directed staff to observe the access site for bleeding every shift, assess the dialysis access site location and skin integrity every shift, and notify the physician of signs and symptoms of infection. The resident had a right tunneled femoral hemodialysis line, and the physician’s orders included a pressure dressing and a clamp at bedside. During multiple observations, the surveyor found a bag with gauze above the resident’s bed but no clamp inside the bag. The Unit Manager stated the resident should have an emergency kit at the bedside including a clamp in case the hemodialysis line breaks, and that line breakage would be a medical emergency requiring immediate clamping and pressure until EMS arrives. The surveyor and Unit Manager were unable to locate the clamp in the resident’s room, and the DON stated nursing should have ensured the clamp was at the bedside according to the physician’s order.
Failure to Ensure Resident Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a resident, who was alert, oriented, and able to communicate needs, was not treated with dignity and respect by a Certified Nurse Aide (CNA) during an overnight shift. The resident, who had multiple sclerosis, paraplegia, a colostomy, chronic wounds, anxiety, and depression, was fully dependent on staff for care and was cognitively intact according to the most recent assessment. During early morning care, the resident reported that the CNA roughly grabbed and squeezed their left wrist, spoke in a rude and disrespectful manner, and laughed at the resident when asked for his name. The incident was reported by the resident to a nurse immediately after it occurred. The resident described that when they were unable to turn as requested by the CNA, the aide became upset, raised his voice, and continued to be rude. The resident also reported that the CNA responded to their request for his name by laughing and leaving the room. Multiple staff interviews confirmed that the resident consistently described the CNA's behavior as rough, rude, and disrespectful, and that the resident felt hurt and disrespected by the interaction. Facility records and staff interviews indicated that the resident's complaints were promptly reported and documented. The facility's internal investigation substantiated the resident's account of being treated in a manner that was not consistent with the facility's policy on resident rights, which requires all residents to be treated with kindness, respect, and dignity. The CNA involved denied being physically or verbally abusive but did acknowledge that the resident complained about rough care and that he apologized.
Delayed and Inconsistent CPR Response for Unresponsive Resident
Penalty
Summary
The Facility failed to ensure that licensed nursing staff had adequate training and the necessary skill set to initiate life-saving measures in an effective and efficient manner when responding to an emergency. The deficiency involved one sampled resident who was found unresponsive while on Full Code status and had diagnoses including COPD, CHF, pulmonary hypertension, atrial fibrillation, and obstructive sleep apnea. The resident’s advance directives indicated full resuscitation measures were to be provided, and the Facility’s CPR policy required immediate assessment, activation of the emergency response system, retrieval of the AED, initiation of the C-A-B sequence, and continued CPR until EMS arrived. According to the Facility’s internal investigation, a nurse found the resident without the BiPAP in place and later found the resident unresponsive. CPR was initiated and 911 was called, and EMS later pronounced the resident dead at the Facility. The report stated the resident had been hospitalized 25 times and that the cause of death was respiratory failure with contributing factor of nonadherence to BiPAP. During interviews, the nurse said she observed the resident with bluish skin, eyes and mouth wide open, and no response to calling or shaking, then began chest compressions and called for help. The interviews also showed uncertainty and inconsistency in the response. The nurse said she did not recall how many compressions or cycles were completed, left the resident briefly to seek help, and was unsure whether the AED was in the room. A CNA said she retrieved the code cart but did not bring the AED and was not sure where it was located. Another nurse said the AED was not applied, she performed bag-mask ventilation, and she was unaware of how many CPR cycles occurred before EMS arrived. The Unit Manager stated the expectation was to never leave the resident alone, call a code, retrieve the code cart and AED, start CPR immediately, and continue compressions until EMS took over.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the appropriate competencies required to care for every resident in a manner that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked the necessary skills or knowledge to provide care tailored to the individual needs of residents. This failure resulted in care that did not fully support or enhance the well-being of all residents as required.
Failure to Provide Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with a history of suicidal ideation (SI) and depression. The resident, who was admitted in February 2023, had a history of depression and dementia and was admitted after vocalizing passive SI. Despite recommendations for a psychiatric consult and medication recommendations, the facility did not implement a care plan for SI after the resident's return from the hospital in August 2023. The medical record lacked evidence of a referral for psychotherapy or an updated plan of care to address the resident's SI. The facility's failure to maintain the highest practicable physical, mental, and psychosocial well-being for the resident was evident when the resident attempted suicide by trying to jump over a second-floor balcony in December 2023. The incident was intervened by the Maintenance Director, and the resident was sent to the hospital. Upon readmission, the facility did not review or update the resident's plan of care, despite the recent suicide attempt. The medical record also failed to indicate that the Psych NP's recommended treatment plan was communicated to staff, implemented, or tracked. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's SI and suicide attempt. The facility's Social Worker was unaware of the resident's history of SI and suicide attempt, and the Nurse Unit Manager acknowledged that the resident should have been evaluated for talk therapy. The Psych NP stated that referrals for psych services were not made, and the resident's physician expected the resident to be followed closely by the facility's Social Worker. The Director of Nursing expressed surprise that the Social Worker was not informed of the resident's history and expected the resident to be assessed by psych services upon admission.
Failure to Provide Appropriate Behavioral Health Services
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a known history of depression, suicidal ideation (SI), and adjustment difficulty. The resident, admitted in February 2023, had diagnoses including depression and dementia. Despite recommendations for a psychiatric consult and medication management upon admission, the facility did not develop or update a care plan addressing the resident's SI. This oversight persisted even after the resident expressed active suicidal ideation in August 2023, leading to hospitalization. Upon the resident's return from the hospital, the facility did not implement or update a care plan to monitor and manage the resident's SI. The resident continued to experience anxiety, sadness, and frustration, yet there was no referral for talk therapy or specific behavioral management interventions. The facility's failure to communicate and implement the Psych NP's recommended treatment plan further exemplified the lack of coordinated care. In December 2023, the resident attempted suicide at the facility, which was prevented by staff intervention. Despite this serious incident, the facility did not review or update the resident's care plan upon readmission. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's history and needs, highlighting systemic issues in managing residents with behavioral health needs.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to significant deficiencies in their care. For one resident, the facility did not create a care plan addressing suicidal ideation (SI) despite the resident's history and vocalization of SI. This oversight resulted in the resident attempting suicide at the facility. The facility's policy required timely intervention and continuous monitoring for residents with SI, but these measures were not implemented. The resident's care plan was not updated after multiple incidents of SI, and the facility staff, including the social worker and nurse unit manager, were unaware of the resident's history and recent suicide attempt. Another resident was admitted with a diagnosis of incontinence, but the facility failed to develop a care plan to address this condition. The resident was consistently incontinent and expressed dissatisfaction with the lack of timely incontinence care, particularly before meals. Despite the resident's repeated requests and the facility's policy to provide prompt incontinence care, the staff did not implement a care plan or provide the necessary interventions. The Director of Nursing and MDS Nurse acknowledged the oversight, noting that an incontinence care plan should have been developed based on the resident's assessment. The deficiencies in care planning for both residents highlight a failure to adhere to the facility's policies and procedures for developing and updating comprehensive care plans. The lack of communication and coordination among staff members contributed to the inadequate care provided to these residents, resulting in unmet medical and psychological needs.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to provide necessary treatment and interventions to prevent and manage pressure ulcers for a resident at high risk. The resident, who was cognitively intact and required assistance with mobility, had a history of pressure ulcers and was assessed to be at high risk for developing new ones. Despite physician orders to offload the resident's heels and maintain specific air mattress settings, these interventions were not consistently implemented. Observations revealed the resident's heels were not offloaded, and the air mattress was set incorrectly, leading to the reopening of a previously healed pressure ulcer on the left upper Achilles heel. Additionally, the facility did not obtain wound care orders for the newly developed pressure ulcer on the resident's left upper Achilles heel. The resident's medical record lacked any documentation of wound care orders for this area, and interviews with nursing staff confirmed that no treatment was in place for the pressure ulcer. The lack of communication and documentation regarding the resident's wound care needs contributed to the deficiency. The facility also failed to conduct and document weekly assessments and measurements of a deep tissue injury (DTI) on the resident's right heel. Despite the presence of the DTI since at least August, there were no recorded assessments or measurements in the past three months. Furthermore, weekly skin assessments were not consistently completed, with documentation missing for eight out of eleven weeks. These lapses in care and documentation highlight significant deficiencies in the facility's pressure ulcer prevention and management practices.
Deficiency in Nursing Staff Wound Care Competency
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and demonstrated the necessary competencies in wound care, as outlined in the Facility Assessment. The surveyors identified multiple deficiencies during the recertification survey, including the failure to implement pressure ulcer prevention interventions, assess and measure wounds weekly, perform hand hygiene during wound care, obtain treatment orders for wounds, notify providers of new wounds, transcribe new wound care orders, and complete weekly skin checks. These deficiencies were linked to the lack of completed wound care competencies for the nursing staff. The review of staff education files revealed that none of the three licensed nurses with identified concerns had completed wound care competencies within the last year. The Director of Nursing acknowledged that the facility's policy required annual completion of these competencies, but there was a gap in staff development due to the absence of a staff development nurse from November 2023 to April 2024, and again from August 2024 to the present. This lack of training and competency assessment contributed to the deficiencies observed in wound care practices.
Failure to Provide Timely Incontinence Care Before Meals
Penalty
Summary
The facility failed to provide a dignified existence for a resident by not addressing their incontinence care needs before meals. The resident, who was cognitively intact and always incontinent of bowel and bladder, repeatedly had to eat breakfast while sitting in a soiled brief. This occurred on multiple days during the survey, and the resident expressed distress over the situation, stating that they had informed staff of their need for incontinence care before meals, but were told that assistance could not be provided during mealtime. The facility's policy on dignity and quality of life, which prohibits demeaning practices and requires prompt response to toileting assistance requests, was not adhered to. Despite the resident's repeated requests and the Director of Nursing's awareness of the issue, the staff failed to provide the necessary care. The resident's medical record also lacked a care plan for incontinence, further contributing to the deficiency.
Failure to Notify Physician and Obtain Wound Care Orders
Penalty
Summary
The facility failed to notify the physician and obtain wound treatment orders for two residents, leading to deficiencies in care. Resident #4, who was admitted with end-stage renal disease and diabetes, had a newly re-developed unstageable pressure ulcer on the left upper Achilles heel and a skin tear on the left hand. Despite the facility's policy requiring significant abnormal findings to be reported to the physician, the provider was not notified, and no wound care orders were obtained for these conditions. Interviews with staff revealed that the pressure ulcer had been present for at least two weeks without treatment, and the dressing on the resident's hand was applied without a physician's order. Resident #269, admitted with diabetes and a right arm fracture, had pressure wounds on the buttocks upon admission. The facility's assessments noted the presence of these wounds, yet the provider was not informed, and no wound care orders were obtained. Observations showed discoloration in the buttocks and perianal area, which staff were unsure how to classify. Despite the facility's policy, the physician was not notified of the skin condition, and no treatment orders were in place. The Director of Nursing acknowledged that the provider should have been notified for both residents to obtain appropriate wound care orders. The failure to communicate these significant changes in the residents' conditions to the physician resulted in a lack of necessary treatment, contrary to the facility's protocols.
Failure to Address Resident Grievances Regarding Staff Sleeping on Duty
Penalty
Summary
The facility failed to address grievances raised by a resident, identified as Resident #31, regarding staff behavior, specifically staff sleeping during night shifts. Despite the resident's repeated complaints to various staff members, including the Director of Nursing (DON) and a social worker, the facility did not follow its grievance policy. The policy requires grievances to be documented and investigated, with a resolution reported to the Administrator within five days. However, no grievances were recorded in the Grievance Log concerning Resident #31's complaints, and the issue persisted over a year. Resident #31, who was cognitively intact, expressed concerns about staff sleeping on duty multiple times, even providing photographic evidence to the administration. Despite these efforts, the resident felt that the complaints were not resolved, as the staff member in question continued to be employed and observed sleeping. During a resident group interview, other residents corroborated the issue, reporting similar observations of staff sleeping during night shifts, which affected the response to call lights. Interviews with staff, including CNAs and nurses, revealed that grievance forms were not consistently completed or filed, and the DON acknowledged awareness of the issue but could not provide documentation of any grievance forms or investigations related to the complaints.
Failure to Implement Abuse Policy for Resident
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident who was admitted with diagnoses including depression and unsteadiness on feet. The resident, who had severe cognitive impairment and required substantial to maximal assistance with transfers, was involved in an incident where a staff member alleged physical abuse by another nurse during an incorrect transfer. The facility's policy mandates that allegations of abuse be promptly reported and thoroughly investigated, with the Administrator and Director of Nursing responsible for implementing corrective actions and measures to prevent recurrence. Despite the facility's policy, the corrective measures following the abuse allegation, which included updating the resident's care plan and follow-up from the Social Worker, were not implemented. The clinical record did not show any updates to the care plan or any assessment by the Social Worker after the incident. During an interview, the Director of Nursing admitted to not updating the care plan and was unsure if the Social Worker had conducted a follow-up, which was not documented in the Social Worker's notes.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The facility failed to investigate allegations of neglect for two discharged residents. The first resident, who was cognitively intact and dependent on staff for toileting tasks, reported an incident where a CNA told them they would be changed later, resulting in a grievance that was not properly addressed. The grievance form's action taken section was left blank, and the summary of findings concluded it was a miscommunication without a thorough investigation. The second resident, also cognitively intact and requiring substantial assistance, reported being left in a chair for nine hours despite multiple requests to be put back to bed. The grievance form indicated that CNAs were spoken to about expectations, but no formal investigation was documented. The Director of Nursing acknowledged these grievances but did not provide any investigation documentation, viewing them as customer service issues rather than neglect.
Failure to Implement Physician Orders for Wound Care and Heel Protection
Penalty
Summary
The facility failed to ensure that services provided met professional standards for two residents. For one resident, the facility did not transcribe and implement a daily wound dressing according to the physician's order for ten days. The resident had a non-pressure wound on the right upper lateral buttock that required daily application of Xeroform gauze, tape, and an ABD pad. Observations revealed that the wound was not dressed, and interviews with staff confirmed that the dressing was not applied as ordered. The Nurse Unit Manager admitted to not transcribing the orders, and the Director of Nursing acknowledged that the orders should have been implemented. Additionally, the same resident had a physician's order to cleanse and dress bilateral lower extremities daily for venous stasis ulcers. However, observations showed that the dressing on the left lower extremity had not been changed for two days, and there was no dressing on the right lower extremity. The nurse confirmed that the dressing should have been changed daily and that there was no documentation of refusal by the resident. For another resident, the facility failed to implement physician orders for heel protection booties. The resident was observed in bed without the booties on multiple occasions, despite orders to apply them while in bed. The Nurse Unit Manager stated that staff should follow the physician's orders and document any refusal by the resident, but the clinical record did not indicate any refusal. This lack of documentation and implementation of orders highlights a deficiency in the facility's adherence to professional standards of care.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide adequate Activity of Daily Living (ADL) care, specifically weekly showers, to three residents, as observed and reported during a resident group meeting. Six out of ten residents expressed concerns about not receiving weekly showers, with three residents being particularly vocal about their unmet needs. Resident #44, admitted with acute respiratory failure, was cognitively intact and dependent on staff for showering. Despite being scheduled for weekly showers, documentation showed that Resident #44 received only one shower in three months, with no records of refusal documented. Resident #14, admitted with chronic respiratory failure, also required substantial assistance for bathing. Despite being scheduled for weekly showers, Resident #14 reported not having had a shower in a long time, and documentation confirmed no showers were provided in the past three months. The care plan for Resident #14 did not address shower needs or the level of assistance required, and there was no documentation of shower refusals. Resident #54, with cerebral palsy and muscle weakness, was dependent on staff for ADLs and reported not having a shower in two years. Observations noted unwashed hair, and documentation indicated only one shower in the past two months, despite being scheduled for twice-weekly showers. The Director of Nursing acknowledged awareness of the issue but believed it had been resolved, yet no refusals were documented in the medical records for any of the residents.
Delay in Hearing Aid Process Due to Untimely Ear Wax Removal
Penalty
Summary
The facility failed to ensure timely implementation of services to maintain hearing for a resident, resulting in a delay in obtaining hearing aids. The resident, admitted in February 2022, had diagnoses including essential tremor, epilepsy, and cognitive communication deficit. Despite having intact cognition and minimal difficulty hearing, the resident had been requesting hearing aids for over a year. An audiologist recommended ear wax removal in December 2024, but the treatment was not implemented until September 2024, nearly nine months later. Interviews with staff revealed that the facility's process for obtaining orders for ear wax removal was not followed promptly. The Director of Nursing acknowledged that orders should be obtained the same day or shortly after a recommendation is made. However, the resident's medical records showed no order for ear wax removal until September 2024, despite a request for an audiology consult being made in April 2024. This delay in treatment led to a significant postponement in the process of obtaining hearing aids for the resident.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to update the care plans or complete falls assessments for two residents after they experienced falls, resulting in deficiencies in care. Resident #38, who was admitted with diagnoses including depression and unsteadiness on feet, experienced multiple falls, including one that resulted in a fracture. Despite these incidents, the care plan for Resident #38 was not reviewed or revised to include new interventions to prevent further falls. The Director of Nursing indicated that the expectation was for the care plan to be updated after each fall, but this was not done. Resident #27, admitted with diagnoses including muscle weakness and difficulty walking, also experienced a fall that resulted in a fracture. The care plan for Resident #27 was not reviewed or revised following this incident. The Director of Nursing stated that the care plan should have been updated after the fall, but it was not. The facility's policy on fall reduction requires that falls be investigated and care plans updated with appropriate interventions, which was not adhered to in these cases. The facility's failure to update care plans and conduct falls assessments after incidents of falls for these residents indicates a lack of adherence to their own fall reduction policy. This oversight potentially contributed to the residents' injuries and highlights a deficiency in the facility's management of fall risks and care plan updates.
Failure to Ensure Proper Communication and Monitoring for Dialysis Care
Penalty
Summary
The facility failed to provide care and services consistent with professional standards for a resident requiring dialysis. The resident, who was cognitively intact and diagnosed with end-stage renal disease, reported that staff often forgot to send the dialysis communication book to the dialysis center. This book was essential for communication between the facility and the dialysis center. The resident's care plan required the communication book to be sent to each dialysis treatment, but the facility did not ensure this was done consistently. The review of the resident's dialysis communication book revealed that post-dialysis weights were not documented for 11 out of 14 scheduled treatments, and there was no follow-up on the missing information in the resident's medical record. Interviews with facility staff, including nurses, the nurse unit manager, the nurse practitioner, the dietitian, and the director of nursing, highlighted a lack of communication and collaboration with the dialysis center. Staff acknowledged the importance of obtaining post-dialysis weights to monitor for complications, but there was a misunderstanding about the facility's responsibility in managing the resident's dialysis care. The nurse unit manager believed the dialysis center was responsible for all aspects of the resident's care, while the nurse practitioner and dietitian emphasized the need for the facility to monitor post-dialysis weights. The director of nursing confirmed that staff should obtain and document weights if the dialysis communication sheet was incomplete.
Failure to Address Pharmacy Recommendations for a Resident
Penalty
Summary
The facility failed to review and address pharmacy recommendations for a resident with severe cognitive impairment and diagnoses including depression and unsteadiness on feet. The resident was admitted in August 2022, and the most recent Minimum Data Set (MDS) assessment indicated a need for substantial to maximal assistance with transfers. A pharmacist's note from September 2024 recommended evaluating the continued need for Enoxaparin and adding a stop date, as well as changing the timing of Atorvastatin administration. These recommendations were repeated in October 2024. However, the physician's orders did not reflect that these recommendations were reviewed or implemented. The Nurse Unit Manager acknowledged that the recommendations were not communicated to the physician due to her absence in September, and they were only signed by the physician a few days before the interview on October 31, 2024.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.45% error rate observed during a medication pass. Nurse #3 made two errors out of 31 opportunities while administering medications to a resident. Specifically, Nurse #3 administered the incorrect type of calcium carbonate without the required vitamin D and minerals and did not clarify the missing dosage. Additionally, Nurse #3 administered ferrous sulfate without clarifying the missing dosage, contrary to the facility's policy that requires medications to be administered in accordance with prescriber orders and verified three times for the correct dosage. The resident involved was admitted with diagnoses including diabetes and hypertension and had severe cognitive impairment. During the medication pass, Nurse #3 was unaware of the need to clarify the orders for the medications that lacked dosage information. Interviews with the Nurse Unit Manager and the Director of Nursing confirmed that the orders should have been clarified before administration, and the correct type of calcium carbonate was not available in the facility. This oversight led to the administration of incorrect medications to the resident.
Improper Storage of Medications in Unlabeled Containers
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with State and Federal laws, specifically by not keeping medications in their original, labeled containers. During an observation, a surveyor and a nurse found two uncovered medication cups with unlabeled pills in a medication cart on the 2nd floor back hallway. One cup contained two white pills, while the other contained two white pills and one blue pill. Nurse #2 admitted to pouring the medications a few hours earlier but had not administered them because the residents were unavailable. She acknowledged that the medications should have been discarded at that time but intended to administer them later. The Director of Nursing confirmed that pills should not be stored in medication cups in the cart and should be discarded if a resident is unavailable or refuses them.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in care. For one resident with diabetes and venous ulcers, the nurses documented a physician's order for wound care as implemented when it was not. The resident's treatment administration record indicated that the wound care was documented as completed on specific dates, but observations and interviews revealed that the dressings were not changed as ordered. The nurse confirmed that the dressing on the resident's left calf had not been changed for two days, and there was no documentation of refusal or rationale for not implementing the treatment. Additionally, the facility failed to complete daily documentation for three residents regarding their bathing and showering tasks. One resident, who was cognitively intact and required substantial assistance, had bathing documentation completed for only a few shifts out of many possible shifts over three months. Interviews with a CNA and the Director of Nursing confirmed that all care provided should be documented on all shifts, and there was significant missing documentation. Two other residents also experienced similar issues with incomplete documentation of bathing tasks. One resident with moderate cognitive impairment and another who was cognitively intact and dependent on staff for bathing had documentation completed for only a fraction of the possible shifts over the same three-month period. The Director of Nursing acknowledged the missing documentation and stated that all care should be documented on all shifts.
Failure to Address Resident Shower Concerns in QAPI Plan
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan addressing residents' concerns about not receiving showers. The deficiency was identified through a review of Resident Council minutes from multiple meetings, where residents consistently reported that scheduled showers were not being provided. During a Resident Group meeting, a majority of participants expressed that they had not had a shower in a long time and did not feel clean. An interview with the Director of Nursing revealed that the issue had not been brought to the QAPI process because the Activities Director, responsible for running the resident council meetings, had not been sharing the minutes with her. Consequently, the Director of Nursing was unaware of the ongoing issue with showers not being provided.
Inadequate Hand Hygiene During Wound and Tracheotomy Care
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively, as evidenced by two specific incidents involving a nurse's inadequate hand hygiene practices. In the first incident, a nurse was observed performing wound care on a resident without adhering to proper hand hygiene protocols. The nurse removed soiled gloves and applied new ones multiple times without performing hand hygiene in between, despite the facility's policy requiring hand hygiene after glove removal. This lapse occurred during the care of both a lower leg wound and a surgical abdominal wound, and the nurse acknowledged the oversight during an interview. In the second incident, the same nurse was observed providing tracheotomy care without following appropriate hand hygiene procedures. After cleansing the tracheotomy tube and handling secretions, the nurse failed to change gloves and perform hand hygiene before applying new, clean tracheotomy ties. This action was contrary to the facility's policy, which mandates glove removal and hand hygiene after contact with body fluids. The nurse admitted to being unaware of the need to change gloves and perform hand hygiene in this context, and the Director of Nursing confirmed the correct procedure during an interview.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to honor the residents' rights to receive written notice before a room change or the introduction of a new roommate. This deficiency affected 21 residents who were alert, oriented, and able to communicate with staff. The facility's policy, revised on December 6, 2021, required that residents be informed verbally and in writing of any room changes or new roommates. However, during the review of clinical records and interviews, it was found that no written notices were provided to the affected residents prior to the changes. The deficiency was identified through a review of the facility's daily census reports and clinical records, which showed multiple room changes and new roommate assignments on August 28 and 29, 2024. Interviews with 15 affected residents confirmed that they did not receive written notice of these changes. Additionally, a representative for one resident reported not receiving any notice prior to the room change. The Medical Records Coordinator confirmed the absence of written notices in the medical records for the sampled residents. Interviews with the facility's Administrator and Director of Nursing (DON) revealed that a corporate directive prompted the immediate relocation of residents from the Short Term Rehabilitation (STR) Unit to the Long Term Care (LTC) Unit. The Administrator and DON acknowledged that the moves could have been postponed to comply with the facility's policy, which required at least 24 hours' notice. They admitted that residents were not shown their new rooms or introduced to their new roommates, and that the affected residents did not have the opportunity to discuss the changes with their families or representatives.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,212 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Reading
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Brook Rehabilitation And Healthcare Center | 2.1 mi | ★★★★★ | 30 | 0 |
| Royal Meadow View Center | 2.4 mi | ★★★★★ | 4 | 0 |
| Care One At Wilmington | 2.7 mi | ★★★★★ | 0 | 0 |
| Bear Hill Healthcare And Rehabilitation Center | 3.7 mi | ★★★★★ | 7 | 0 |
| Regalcare At Wakefield | 4.1 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.