Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allegany Health Nursing And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility failed to hold and document an interdisciplinary care plan meeting after completion of an MDS assessment for a resident with a urinary catheter. The social worker reported that care conferences are usually scheduled about 2 weeks after MDS assessments and documented in the EHR. Record review showed an MDS completed for the resident, but the only documented care conference was several months earlier, with no subsequent meeting held. The social worker and NHA confirmed that no care plan meeting had occurred since that earlier date, attributing this to the resident’s transition from LTC to skilled care.
A resident was readmitted from the hospital with an indwelling Foley catheter placed for urinary retention, with instructions for outpatient urology follow-up. The facility documented ongoing catheter orders and noted the device on the MDS, but failed for several months to include the catheter in the resident’s care plan or to develop interventions related to its use. No timely urology appointment was arranged, and there was no documentation of any attempt to discontinue the catheter, even after the resident developed hematuria and was treated for cystitis. The facility also lacked a facility-specific policy addressing catheter use and plans for discontinuation.
A resident’s MDS did not accurately reflect a documented pressure injury. A wound specialist noted an unstageable DTI on the resident’s right lateral foot, but the MDS recorded no unhealed pressure ulcers or injuries. The MDS Nurse later confirmed the resident had a DTI and stated the assessment needed correction.
Failure to Provide Individualized Activities for Residents with Dementia: Two residents on a secured unit with dementia had limited evidence of meaningful activity engagement despite documented preferences and care plan interventions. One resident who was legally blind was repeatedly observed alone or inactive while records mainly showed self-directed socialization and walking in the halls, with little documentation of the preferred reading, music, group, outdoor, or religious activities. Another resident with severe cognitive impairment had activity logs dominated by TV and self-directed socialization, while survey observations showed the TV was difficult for hallway residents to view and a room that could have been used for activities was not used for that purpose.
Failure to Evaluate Nursing Staff Competency: Nursing staff were not evaluated for competence as required. Review of two RNs' files found one had no skills or competency documentation and the other had only two competencies from 2021, with no more recent evaluations. The HR Coordinator and DON both confirmed that nursing staff should have competencies completed during orientation and annually, but these two RNs did not have their skills or competence evaluated.
The facility failed to ensure that two GNAs had performance evaluations in their employee files. Record review found no evidence of evaluations for either staff member, and the DON confirmed the evaluations had not been completed.
Controlled substance reconciliation records were not accurately completed for a medication cart. Two nurses signed the shift count sheet without documented evidence that an actual count of narcotic blister packs, medication bottles, refrigerated meds, or transdermal patches was performed, and an LPN pre-signed the next shift's reconciliation before the count occurred.
Inaccurate eMAR documentation was identified when an RN prepared to give a resident's amantadine for Parkinson's disease and the record showed it as already administered even though it had not yet been given. The RN later administered the medication and corrected the entry to show it was late, and the RN, NHA, and DON acknowledged the concern.
Failure to Use Infection Prevention Strategies: Laundry staff were observed handling dirty linens without gowns or aprons, and one aide folded a sheet that touched the floor. The facility also lacked an effective Legionella water management program, with no Legionella testing and only limited water temperature logs. In addition, during wound care for a resident with a stage 4 pressure ulcer, PPE was not properly worn and the resident’s EBP order applied only to a Foley catheter, not the wound.
A resident’s call bell was found on the floor under the bed and was not within reach when the resident requested help with a nasal cannula. A GNA later retrieved the call bell and stated it had previously been placed on the bed, but it was not clipped and the resident was seated in a wheelchair next to the bed. The DON acknowledged the concern.
Missing Annual Training for a GNA: Record review and DON interviews showed that one GNA did not have documentation of the required 12 hours of annual training. The DON reported no training records were available and later confirmed that the GNA had not completed the annual training requirement.
A resident was admitted without a clear physician's order for end-of-life care, and facility staff failed to initiate CPR when the resident was found not breathing. Despite prior education on CPR and MOLST forms, an LPN and RN supervisor did not act due to the absence of a completed MOLST form, leading them to wait for EMS. The facility's policy required staff to treat residents as full code in emergencies without a completed MOLST form.
Two residents suffered injuries due to staff failing to follow care plans in a LTC facility. One resident fell out of bed during incontinence care, resulting in bilateral femoral neck fractures, as the GNA did not use the required two-person assist. Another resident sustained a fractured humerus during a manual transfer to a shower chair, contrary to the care plan requiring a lifting device. Staff did not verify care plans before performing tasks, leading to improper handling and supervision.
A resident was subjected to abuse when a staff member, GNA2, kicked them on the leg, causing a skin tear, after the resident attempted to remove food trays. The incident was witnessed by an LPN who reported it to a supervisor. GNA2 was verbally aggressive and attempted to move the resident backward before the physical altercation occurred.
The facility failed to implement its abuse policy when two staff members reported an allegation of sexual abuse between two residents. An anonymous complaint indicated that the administration required a nurse to retract documentation of the incident, and the facility did not report the abuse to the State Survey Agency. Despite the facility's policy requiring immediate reporting and investigation, no formal documentation or notification to authorities occurred.
A facility failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. The incident involved two residents, with one observed touching the other's genitals. Despite being reported to the Director of Social Work and the facility Administrator, no proper documentation or investigation was conducted, and the incident was not reported to authorities as required by facility policy.
A facility failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff. The incident involved two residents, with one observed touching the other's genitals. Despite being informed, the facility's leadership did not document or investigate the incident, nor did they notify the local police or State Survey Agency, contrary to their policy.
A resident was improperly restrained in a geriatric chair and wheelchair with a lap tray, preventing her from standing up, which was done for staff convenience. The facility's policy requires restraints to be used only as a last resort with proper documentation, which was not followed. The resident, who was cognitively intact, expressed anxiety due to the inability to move freely, and staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints.
A facility failed to update a resident's care plan to include the use of a geriatric chair and lap trays, which were used as restraints. The resident, cognitively intact, was placed in these devices after a fall, but the care plan did not reflect this. Staff confirmed the oversight, and the DON and Administrator did not recognize these as restraints, leading to potential safety risks.
Failure to Hold Interdisciplinary Care Plan Meeting After MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an interdisciplinary care plan meeting was held to review and revise a resident’s care plan following completion of a Minimum Data Set (MDS) assessment. Care conferences, also known as care plan meetings, are required interdisciplinary team meetings that are to occur after MDS assessments, which provide the information needed to develop and modify the resident’s care plan. Interview with the social worker revealed that MDS nurses send out a schedule and social work typically schedules care plan meetings 14 days after the assessment date, with documentation of these meetings maintained in the electronic health record. Medical record review for a resident with a urinary catheter showed an MDS with an assessment reference date of 1/9/26. Further review of the record revealed documentation of a care conference on 10/15/25, but no documentation of any care conference occurring after the 1/9/26 MDS assessment. When questioned, the social worker and the Nursing Home Administrator confirmed that no care plan meeting had been held since October, and the NHA stated this was due to the resident transitioning from long-term care to skilled care. This failure to hold and document an interdisciplinary care plan meeting after the MDS assessment constituted the cited deficiency.
Failure to Care Plan and Reassess Indwelling Foley Catheter Use
Penalty
Summary
Surveyors identified a failure to develop and implement a care plan addressing an indwelling urinary catheter and to assess for its possible removal for a resident who had been readmitted from the hospital with a Foley catheter in place. The resident had previously resided in the facility for more than a year and, prior to a hospital stay in late December, was documented on the discharge MDS as frequently incontinent of urine without any internal or external catheter. During the hospitalization, the resident developed urinary retention and urology placed a Foley catheter with the plan for it to remain in place at discharge and for the resident to follow up with urology as an outpatient. Upon the resident’s readmission in early January, facility records showed ongoing orders for an indwelling Foley catheter and catheter care every shift, and the MDS assessment dated shortly after readmission documented the presence of an indwelling urinary catheter. However, review of the care plan on April 1 revealed no documentation acknowledging the catheter or interventions related to its use, despite the catheter having been in place since January. The existing care plan only addressed occasional bladder and bowel incontinence and, even when it was reviewed and revised in March by an RN, it still did not address the indwelling catheter or the resident’s recent urinary issues. Further record review showed no orders for a urology appointment and no documentation that the resident had been seen by urology or that any attempt had been made to discontinue the catheter after readmission. Progress notes from primary care providers in early January referenced the difficult Foley placement and the need for outpatient urology follow-up, but this follow-up was not arranged at that time. In March, the resident developed hematuria and was treated for cystitis with hematuria, yet the care plan remained unchanged and still did not address the catheter or the recent urinary tract infection. The facility also lacked a facility-specific policy on catheter use and discontinuation, relying instead on a textbook reference that noted complications associated with indwelling catheter use.
MDS Did Not Reflect Resident’s Pressure Injury
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected a resident’s current status. Medical record review showed that a wound specialist documented an unstageable deep tissue injury (DTI) on the resident’s right lateral foot, but the MDS assessment with an assessment reference date of 3/13/26 recorded in Section M0210 that the resident had no unhealed pressure ulcers or injuries. During interview, the MDS Nurse reviewed the electronic health record and acknowledged that the resident did have a DTI on the foot, stating that the MDS would need to be modified to correct the assessment. Later documentation provided by the MDS Nurse showed a correction was submitted to reflect one unhealed, unstageable pressure injury presenting as a DTI.
Failure to Provide Individualized Activities for Residents with Dementia
Penalty
Summary
The facility failed to ensure the provision of activities to meet the needs of residents with dementia for two residents on the secured unit. Resident #122 had resided at the facility for more than 6 months, was legally blind, and had dementia. The resident was observed multiple times in the hallway or alone in the room, including standing in the room with no television or music on, reclining on the bed, and sitting in the hallway while bingo was being called but not participating. On several observations, no organized activity was occurring on the unit, and the resident was not engaged in an activity at those times. Resident #122’s MDS activity preferences indicated it was very important to have books, newspapers, and magazines to read; listen to music; be around animals; keep up with the news; do things in groups; go outside for fresh air; and participate in religious services. The care plan included interventions such as audiobooks, staff assistance with reading mail and information sheets, and one-to-one visits for socialization and assistance with audio equipment. A care conference note stated the resident’s representative wanted the resident to be more engaged with activities. However, the activity participation records for January, February, and March 2026 primarily documented self-directed active socialization and walking in the halls, which the Activity Director stated were not 1:1 interventions and were independent activities. The records showed limited participation in bingo, socials, snacks/hydration, a pet visit, mail reading, fresh baked cookies, and the barber/beauty shop, with no documentation that several preferred or individualized activities were offered or provided as described in the care plan. Resident #9 had resided at the facility for more than one year, had dementia with severe cognitive impairment, and had a March 2026 BIMS score of 1/15. The resident lived on the secured unit. The activity preference assessment showed it was very important to go outside for fresh air and somewhat important to have books, newspapers, and magazines to read. The care plan stated the resident was dependent after set-up assistance for emotional, intellectual, physical, and social needs and included interventions such as offering music, reading mail and other materials, pet visits, guessing games, and television upfront. Activity logs showed repeated documentation of self-directed socialization and television upfront, along with occasional pet visits, mail reading, family visits, and a few isolated activities. Survey observations showed a large television playing at the back of the nursing station, but residents in the hallway had to look past the counter and staff to view it. A room at the end of the unit that appeared to be a dining room was not observed being used for dining or activities, and a nurse stated there was no specific activity person assigned to the secured unit and that residents were never taken to that room for activities.
Failure to Evaluate Nursing Staff Competency
Penalty
Summary
Nursing staff were not evaluated for competence, as shown by record review and interviews with facility leadership. The Human Resources Coordinator stated that staff performance was monitored annually and that a form with a skills/competencies section was given to the DON and then to the unit manager. Review of the employee file for one RN who was hired to do wound care did not reveal any skills or competency documentation, and the DON said the nurse may not have had a skills checklist completed. Review of another RN's file showed only two competencies dated 3/18/21, one for blood glucose monitoring and one for medication administration, with no more recent competencies found. The DON later confirmed that nursing staff should have competencies completed during orientation and annually, and acknowledged that both RNs did not have their skills or competence evaluated.
Failure to Evaluate GNA Performance
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants had their performance evaluated. Record review showed that employee files for Staff #14 and Staff #15 did not contain any evidence of performance evaluations. During interview, the Director of Nursing confirmed that performance evaluations had not been completed for either GNA.
Controlled Substance Reconciliation Records Not Verified
Penalty
Summary
The facility failed to ensure the accuracy and integrity of controlled substance reconciliation records in 1 of 3 medication storage areas observed, specifically the 3rd floor south cart. During observation of the 3rd floor medication storage room and south medication cart, an LPN provided the narcotic count verification sheet used for shift-to-shift reconciliation of controlled medications. Review of the documentation showed that the 6:00 AM reconciliation for 04/02/26 had signatures from two licensed nurses, but there was no documented evidence that an actual count of controlled medications was performed, including the total number of narcotic blister pack cards, medication bottles including refrigerated medications, or transdermal patches. The 2:00 PM reconciliation for 04/02/26 was signed in advance by the LPN before the required reconciliation time and before completion of a narcotic count with another licensed nurse. During the surveyor's observation, the LPN confirmed that the 2:00 PM reconciliation had been pre-signed because of working a 16-hour shift and stated that the narcotic count had not yet occurred when the signature was entered. The Nursing Home Administrator and DON acknowledged the concern related to narcotic count reconciliation practices.
Inaccurate eMAR Documentation for Medication Administration
Penalty
Summary
The facility failed to ensure the accuracy of clinical records, specifically the eMAR, for one resident during a medication administration observation. Resident #15 had diagnoses including Parkinson's disease, repeated falls, and muscle weakness, and had an order for amantadine HCl 100 mg scheduled for 8:00 AM. During the observation, RN #11 was preparing to administer the resident's medications, and the eMAR showed the amantadine as already administered even though the medication had not yet been given. RN #11 later administered the medication at approximately 9:40 AM and corrected the eMAR entry to reflect a late administration before giving it to the resident. RN #11 stated they were unsure how the medication had been documented as administered before it was actually given, and the NHA and DON acknowledged the concern during interview.
Failure to Use Infection Prevention Strategies
Penalty
Summary
The facility failed to use infection prevention strategies during laundry processing. During observation of the laundry room, a laundry aide was seen folding a flat sheet that touched the floor while she held it up to fold it, and the table available for folding was partially covered with supplies and appeared too short for the sheet. When interviewed, the aide described sorting dirty linens, washing, drying, folding, storing, and stocking linens, and said she wore gloves but did not wear a gown or apron when sorting dirty linens or placing them in the washer. A second laundry aide was later observed sorting dirty linens from a reusable cloth bag, including linens that appeared wet and smelled of urine, while wearing gloves but not an apron or gown, and she stated that she did not wear those items when processing dirty linens and was doing it the way she had been taught. The facility also failed to have an effective water management program for Legionella. The Maintenance Director stated that the facility’s water supply came from the city, that he checked the city’s water report annually, and that the facility did not test for Legionella. He also said he sometimes did random water temperature testing and would provide a report. The Nursing Home Administrator stated that the facility had talked about a water management plan but could not identify a professional reference used or explain any process in place to monitor the water. A water temperature log that was reviewed covered only May 2025 and listed random resident rooms and corresponding temperatures, with no other evidence of ongoing monitoring provided. The facility also failed to provide proper enhanced barrier precautions during wound care for a resident with a stage 4 pressure ulcer on the lower back. During dressing change observation, the contracted wound care physician and wound care RN were completing care for the resident, and the physician prompted the RN to put on PPE, including a gown. However, the physician did not properly don the gown and left it untied and unsecured so that it draped off the arms and cuffed around the hands while assessing and redressing the wound. The resident’s record showed an order for enhanced barrier precautions, but the order specifically applied to a Foley catheter dated 02/06/26, and there was no active order reflecting enhanced barrier precautions for the stage 4 pressure ulcer. The NHA and DON acknowledged concerns about not providing proper enhanced barrier precautions for the resident.
Call Bell Not Accessible to Resident
Penalty
Summary
The facility failed to ensure that a working call system was accessible in a resident’s bathroom and bathing area, as evidenced by Resident #46. During observation, Resident #46 motioned for the surveyor to enter the room while holding a nasal cannula and requested assistance to place it back on. At that time, no call bell was within the resident’s reach, and the call bell was observed on the floor under the resident’s bed. When GNA #17 later entered the room, they retrieved the call bell from under the bed and stated they had previously placed it within the resident’s reach on the bed during their last check. GNA #17 also stated the call bell was not clipped and that the resident was seated in a wheelchair next to the bed at the time of observation. The DON acknowledged the concern regarding the accessibility of the call bell for Resident #46.
Missing Annual Training for GNA
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) received the required 12 hours of annual training. During record review and interviews, the Director of Nursing (DON) was asked to provide training records for GNA #14 and reported that no training records were available. The DON was later asked again to provide any additional evidence of training for GNA #14, and by the end of the survey she confirmed that GNA #14 did not have 12 hours of annual training. No additional evidence was provided by the end of the survey on 4/3/26.
Failure to Initiate CPR Due to Incomplete MOLST Form
Penalty
Summary
The facility staff failed to identify a newly admitted resident who was admitted without a clear physician's order for end-of-life care and did not follow the facility policy to initiate Cardiopulmonary Resuscitation (CPR). This deficiency was evident for one resident during an annual recertification survey. The resident was admitted from the community and had been evaluated in the emergency room earlier in the day. Upon admission, the resident was assessed by a physician and deemed incapable of understanding any information, necessitating a third party to make decisions on their behalf. During the night, the resident was found on a floor mat by the bed but showed no evidence of injury and was placed back in bed. Later, a staff member noticed changes in the resident's breathing pattern and alerted an LPN, who assessed the resident and found them not breathing with eyes rolled back. The LPN notified 911/EMS and applied oxygen but did not initiate CPR. The LPN and an RN supervisor reviewed the resident's medical record and could not find a completed MOLST form, leading them to wait for emergency services to arrive. CPR was not performed, and the resident was pronounced deceased by EMS upon arrival. Interviews with staff revealed that the LPN had received prior education on CPR and MOLST forms but did not act due to the absence of a completed MOLST form. The former Social Work Director stated that newly admitted residents without a completed MOLST form should be considered full code in emergencies. However, there was no documentation of advance directives or MOLST status in the resident's progress notes. The facility's policy indicated that in the absence of appropriate DNR identification or orders, staff should respond with CPR measures and treat the resident as a full code.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility staff failed to provide adequate supervision and follow the resident's plan of care, resulting in harm to two residents. In the first incident, a resident with cognitive impairment and total dependence on staff for care fell out of bed during incontinence care, leading to bilateral femoral neck fractures. The GNA responsible for the resident's care did not adhere to the care plan, which required two staff members for bed mobility. The GNA turned the resident onto their side and left them unattended while seeking additional supplies, resulting in the resident rolling out of bed. In the second incident, another resident with a history of a fractured hip, dementia, and metabolic encephalopathy suffered a fractured humerus during a transfer to a shower chair. Two GNAs attempted to transfer the resident manually, contrary to the care plan that required the use of a lifting device. During the transfer, they heard a popping sound and lowered the resident to the floor. The GNAs had not reviewed the resident's updated care plan, which specified the use of a Hoyer lift for transfers. Both incidents highlight a failure to adhere to established care plans and protocols, resulting in significant injuries to the residents. The staff involved did not verify the residents' care plans before performing tasks, leading to improper handling and supervision. These deficiencies were identified during a survey, and the facility was found to have past noncompliance with a compliance date established after corrective measures were implemented.
Resident Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure that a resident remained free of abuse, as evidenced by an incident involving a staff member, GNA2, who was witnessed kicking a resident on the right lower leg. This incident occurred when the resident attempted to remove food and meal trays from a food cart. GNA2, who was verbally aggressive, attempted to move the resident backward by holding the wheelchair handles and subsequently kicked the resident, resulting in a skin tear. The resident expressed distress by screaming and wheeling themselves down the hall, where they were later found crying by another staff member, LPN5, who observed the injury and reported the incident to a supervisor. The incident was substantiated through witness statements, including that of LPN5, who detailed the sequence of events leading to the abuse. The resident was initially told by GNA2 to return to their room after being informed they had already eaten. Despite the resident's request to be left alone, GNA2 persisted in trying to move the resident, leading to the physical altercation. The facility's investigation confirmed the abuse, and GNA2 was immediately suspended and subsequently terminated following the incident.
Failure to Implement Abuse Policy and Procedures
Penalty
Summary
The facility failed to implement its existing abuse policy and procedures when an allegation of sexual abuse was reported by two staff members. An anonymous complaint revealed that a resident was observed sexually assaulting another resident, and the facility administration allegedly required a licensed nurse to retract their documentation of the incident. Furthermore, the facility did not report the allegation of resident-to-resident sexual abuse to the State Survey Agency. Interviews with the Director of Social Work and the facility Administrator confirmed that an investigation was initiated, but there were no administrative documents or investigative records regarding the alleged abuse. Additionally, the local police and the State Survey Agency were not notified. The facility's leadership did not adhere to its policy, which mandates immediate reporting of alleged violations involving abuse, neglect, exploitation, or mistreatment. The policy requires reporting to the State Survey Agency within two hours of receiving an allegation and conducting a prompt investigation. However, the facility failed to document the incident properly, did not collect witness statements, and did not notify the appropriate authorities. The staff were aware of the resident's history of intrusive behaviors, yet no formal investigation or documentation was completed, leading to a deficiency in handling the reported abuse incident.
Failure to Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility administrative staff failed to report an allegation of resident-to-resident sexual abuse to the State Survey Agency. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The incident was initially reported by a GNA to the Director of Social Work, who then informed the facility Administrator and the Director of Nurses. However, the facility did not document or investigate the incident properly, and no report was made to the State Survey Agency or local police. The facility's policy requires immediate reporting of such allegations, but this was not adhered to. The nurse who documented the incident in the alleged perpetrator's medical record found that the progress note was later marked as invalid, and no formal witness statements were collected. The facility Administrator admitted that there were no administrative documents or investigative records regarding the alleged abuse, and the staff were aware of the resident's intrusive behaviors but failed to take appropriate action.
Failure to Investigate Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility administrative staff failed to investigate an allegation of resident-to-resident sexual abuse when it was reported by staff members. This incident involved two residents, where one was observed with their hands inside the other's brief, touching their genitals. The Director of Social Work was informed of the incident and reported it to the facility Administrator and the Director of Nurses. However, there were no administrative documents or investigative records regarding the alleged abuse, and the local police and State Survey Agency were not notified. The facility's policy requires immediate reporting and investigation of any allegations of abuse, but this was not followed. A staff nurse documented the incident in the alleged perpetrator's medical record, but the progress note was later marked as invalid without explanation. The nurse who reported the incident was not asked to provide a formal witness statement or interviewed by administrative staff. The facility's leadership failed to conduct a prompt investigation or implement immediate actions to safeguard the residents involved.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as observed with one resident who was placed in a geriatric chair and a wheelchair with a lap tray. These devices prevented the resident from standing up, which was done for staff convenience rather than medical necessity. The facility's policy clearly states that restraints should only be used as a last resort and must be documented with a physician's order reflecting a qualifying medical symptom, which was not done in this case. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was observed multiple times in a geriatric chair and a wheelchair with a lap tray, unable to stand or move freely. The resident's care plan did not include any interventions or assessments for the use of these restrictive devices. Staff interviews revealed a lack of awareness and assessment regarding the use of these devices as restraints, and the resident expressed feelings of anxiety and nervousness due to the inability to move freely. Interviews with the Director of Nursing (DON) and the Administrator indicated that they did not consider the geriatric chair with an overbed table or the wheelchair with a lap tray as restraints, and no assessments or care planning were completed to ensure the resident's safety. The resident was often placed in these devices without attempts to allow her to sleep in her bed, further indicating the use of these devices for staff convenience rather than the resident's best interest.
Failure to Revise Care Plan for Restraint Use
Penalty
Summary
The facility failed to revise the care plan for a resident to include the use of a geriatric chair and lap trays, which were considered restraints. The resident, who was cognitively intact with a BIMS score of 14 out of 15, was admitted to the facility and later placed in a geriatric chair after a fall. However, the care plan did not reflect the use of these devices, which were intended to prevent falls. Observations revealed the resident was often placed in a geriatric chair or a wheelchair with a lap tray, and staff intervened to keep the resident seated, indicating the devices were used as restraints. Interviews with nursing staff, including LPNs and RNs, confirmed that the care plan had not been updated to include the use of these restrictive devices. The MDS nurses were unaware of the resident's placement in a geriatric chair and the use of a lap tray, and the Director of Nursing and Administrator did not consider these devices as restraints. This oversight placed the resident at risk for unmet care needs and safety risks, as there was no assessment or care planning to ensure the resident's safety with these devices.
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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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Nursing homes near Cumberland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devlin Manor Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 29 | 0 |
| Cumberland Healthcare Center | 1.8 mi | ★★★★★ | 27 | 1 |
| Lions Rehab Center | 2 mi | ★★★★★ | 34 | 0 |
| Frostburg Rehab Center | 7.8 mi | ★★★★★ | 54 | 0 |
| Mountain City Rehab Center | 8.7 mi | ★★★★★ | 33 | 0 |
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