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 Anchorage Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including morbid obesity, DM II, Stage 5 CKD, prior CVA with left-sided weakness, dementia, and other comorbidities, experienced a significant weight loss of 7.9% in one month as documented in the EMR. Facility policy required immediate notification of the resident, the practitioner, and the resident’s representative for significant changes in condition, such as this weight loss. The EMR generated a significant weight change alert, but another staff member cleared the alert, and department managers and the resident’s physician were not promptly informed of the change, resulting in a failure to provide required notification.
A resident with multiple comorbidities and an order for weekly skin assessments developed a new open area under the left great toenail that was initially identified and reported, with wound care orders put in place. However, required follow-up assessment tools were not completed, weekly skin integrity reviews for several weeks documented either no skin issues or lacked any detailed assessment of the toe wound, and the care plan was not updated to address the non-pressure wound. Later, an RN found the toe swollen, red, warm, tender, with the toenail and surrounding skin detached and dark discoloration of the toes; a CRNP then assessed a full-thickness infected wound with exposed subcutaneous tissue and moderate serosanguineous drainage. The resident was transferred to the hospital, where the wound was associated with MRSA bacteremia and the resident subsequently underwent a left below-knee amputation.
The facility failed to maintain firmly secured handrails on two of four floors, despite a maintenance policy and a high-priority work order noting needed repairs. Surveyors observed long sections of hallway handrails on the second floor detached from the wall and additional unsecured and missing handrails on the third floor. A CMA and the Resident Council President reported the handrails had been unrepaired for several months and noted that some residents rely on them for safety. The Maintenance Director and NHA both acknowledged awareness of the problem, with the NHA citing delays in obtaining materials as a reason repairs had not been completed.
A resident with acute and chronic respiratory failure, OSA, and severe obesity was readmitted from the ED after severe hypoxia requiring BIPAP and aggressive diuresis. The facility physician documented the need for pulmonary follow-up and possible PFT and CPAP, and later stated he had communicated to nursing that the resident required a pulmonary test and CPAP. The resident’s care plan addressed altered respiratory status and OSA and directed staff to report abnormal findings and monitor vitals. However, due to miscommunication between the physician and nursing staff, no CPAP order was written or processed, despite facility policy requiring timely handling of physician orders. The resident’s cause of death was recorded as congestive heart failure.
A cognitively intact resident with an order for turning and repositioning every 2 hours for wound management had multiple missed entries on the TAR where the intervention was not signed as completed. The care plan required encouraging or assisting the resident to turn and reposition and ensuring this was done. The resident reported prior concerns about not being turned every 2 hours. An LPN and an RN stated they performed the turning and repositioning but forgot to document it, and the DON and Administrator confirmed that staff were expected to document treatments and interventions at the time of care.
Persistent Urine Odors Throughout Facility: The facility failed to maintain a sanitary and comfortable environment when surveyors repeatedly detected a strong, pungent urine odor in the main lobby and multiple resident hallways across several floors. A visitor reported the odor is always present in the lobby and on the 3rd floor, and staff stated soiled linen and trash carts are kept on the floors and left in resident hallways.
Infection control practices were not followed during resident care, medication administration, oxygen equipment use, and laundry handling. A GNA entered and exited multiple resident rooms without hand hygiene, a CMA and a UM failed to clean BP cuffs and other vital sign equipment between uses and did not perform hand hygiene as required, several hand sanitizer dispensers on a unit would not dispense sanitizer, a resident’s oxygen humidifier bottle and tubing were in use without dates, and the soiled laundry room contained loose, unbagged, and visibly soiled linens and garments scattered on the floor and equipment.
A GNA entered multiple resident rooms during breakfast tray collection without knocking or asking permission before entering. The surveyor observed the entries, and the ADON stated that staff are expected to knock and ask permission before entering a resident's room.
Surveyors found multiple areas with damaged, worn, and unclean conditions, including resident rooms, bathrooms, a ceiling near the nursing station, and a shared shower room. Observations included stained and chipped walls, rust and debris in vents and ceiling areas, an uncovered light fixture with exposed bulbs, a soap dispenser with debris, a toilet without a tank cover, and wet toilet paper on a toilet seat. In the shower room, surveyors saw used razors, a stained shower bed mattress, a broken toilet wrapped in plastic, a used face mask, used Band-Aids, and debris on the floor.
A kitchen employee verbally threatened a resident during a dispute, telling the resident he could put something into the resident’s food. Another resident who was present heard the threat and corroborated the allegation, and the facility’s investigation substantiated abuse.
Missing Ombudsman and Bed Hold Notifications: The facility failed to document required Ombudsman notices for resident transfers and discharges and failed to provide written transfer and bed hold notice to a resident representative. Surveyors found missing records for multiple residents, including a hospital transfer due to abnormal lab values and a discharge home, and a SW acknowledged monthly Ombudsman emails were not being sent consistently.
Two residents did not have documentation showing that they or their representatives received a written summary of the baseline care plan. One resident was admitted for hyperglycemic management and PT/OT, and the other had a care conference note discussing the plan of care, but both records lacked proof of receipt of the baseline care plan summary. SW confirmed the baseline care plan should be completed within 48 hours of admission and reviewed at the initial care plan meeting, with receipt documented in the chart.
Incomplete Person-Centered Care Plans: Two residents lacked complete person-centered care plans. One resident receiving palliative/comfort care had a MOLST with DNR option B and multiple treatment limitations, but the care plan only addressed code status and did not include palliative care needs such as symptom management, comfort measures, or support for the resident and family. Another resident admitted for hyperglycemic management and PT/OT with plans to return home did not have discharge planning included in the care plan.
The facility failed to ensure residents and/or their representatives participated in care plan meetings with the full IDT, failed to complete quarterly care plan meetings for a resident, and failed to keep care plans accurate when conditions changed. Care conference records for two residents showed only the resident representative, SW, and DOR were present, while a resident reported quarterly meetings were not being completed. The DON also confirmed that one resident’s care plan still reflected hospice services after hospice discharge and another resident’s care plan still listed full code status despite a MOLST showing No CPR.
Unattended housekeeping carts were found unlocked with cleaning chemicals inside on two floors during the annual survey. An staff member confirmed the locks were broken and stated the carts should be locked at all times to prevent residents from getting into them.
A resident with a tracheostomy was observed receiving oxygen through dirty tubing with an empty humidification bottle, while the resident reported the trach was not being cleaned and humidification water had been empty for days. Staff also failed to keep the ordered spare trach at the bedside, and the oxygen concentrator was later found set below the ordered flow rate before being adjusted after surveyor intervention.
Inadequate staffing and delayed resident assistance on the second floor. The unit had an LPN, two GNAs, and a unit manager listed, but the unit manager was not yet present early in the shift. Surveyors observed multiple unmet resident needs, including urinals left near a resident’s water, a resident calling out to get out of bed, an empty PPE container, a full urinal hanging by a bed, a wheelchair out of reach, and a resident standing in a doorway in an incontinence brief asking for help getting dressed. A resident and a family member also reported that staff were limited and sometimes did not respond.
Failure to Document Offer of Advance Directives: A resident’s record contained no documentation that advance directives were offered. The admission packet included advance directive information, and staff reported residents receive this information on admission, but the DSW confirmed there was nothing documented for the resident and the Administrator stated the expectation was for the SW to document the offer.
A resident with an abnormally high WBC count and on an NPO diet was not properly monitored or reported when a change in condition and an incident occurred. The facility failed to notify the physician and resident representative, and did not document the events as required by policy.
A resident with swallowing difficulties and on an NPO diet was found with a grape ice pop in their mouth, but staff did not document a change in condition or monitor for aspiration. Additionally, an abnormally high WBC count was not addressed or followed up with appropriate documentation or assessment.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and representative after a significant change in condition, specifically a significant weight loss. The facility’s policy on Notification of Change in Condition requires informing the resident, consulting with the resident’s medical practitioner, and/or notifying the resident’s representative or authorized family member when there is a significant change in the resident’s physical, mental, or psychosocial condition, including deterioration in health or clinical complications. During a complaint survey, it was determined that this policy was not followed for one resident. The complaint alleged that this resident was not provided with quality of care, prompting review of administrative documents, a closed medical record, and staff interviews. The resident involved had multiple diagnoses, including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, prior stroke with left-sided weakness, polyneuropathy, anemia in chronic kidney disease, hyperlipidemia, dementia, Vitamin D deficiency, GERD, and arthritis due to Lyme disease. A BIMS score obtained earlier showed severe cognitive impairment (6/15). Review of the resident’s record showed a weight of 199.3 pounds in early December and 183.0–183.5 pounds in early January, representing a 7.9% (15.8-pound) weight loss in one month. The facility dietician stated that the electronic medical charting system generates alerts to department managers for significant changes in condition, and that significant weight loss is an alert item. The resident’s significant weight loss was identified and confirmed, but another staff member cleared the weight loss alert, and as a result, department managers and the resident’s physician were not immediately made aware of the significant change in condition, constituting the cited deficiency.
Failure to Assess and Monitor Non-Pressure Toe Wound Leading to Infection and Amputation
Penalty
Summary
The facility failed to provide updated non-pressure wound assessments and failed to identify and monitor a new wound on a resident’s left great toe, resulting in delayed treatment for an infected wound. The resident had multiple diagnoses including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, stroke with left-sided weakness, and dementia, and had a physician order for weekly skin assessments to be documented every Monday. On 12/30/2025, a staff member alerted the unit manager LPN to a 0.5 cm open area under the resident’s left great toenail; the LPN observed the wound, documented the change in condition, and notified the physician and family. The physician ordered lab work, a venous doppler, and dressing care with betadine wet-to-dry dressings every shift. An assessment form completed that morning triggered a skin change in condition and indicated that a Braden Observation tool, Pain Observation tool, and Skin Grid (Pressure and Non-Pressure) tool should be completed and placed in the record, but there was no evidence that any of these three assessment tools were completed. Subsequent documentation failed to reflect ongoing assessment or monitoring of the left great toe wound. The doppler results reported on 12/31/2025 showed mild peripheral vascular disease in the left lower extremity without occlusion. However, review of the January Weekly Skin Integrity Reviews revealed no mention of the left great toe wound’s status, including any measurements or descriptions, for several weeks. On 01/05/2026, an LPN documented there were no skin areas; on 01/12/2026, another LPN documented there were no skin areas since the last skin check; and on 01/19/2026, an RN documented there was a skin area but did not attach an assessment of the left great toe. During this period, the resident’s care plan, which had previously identified risk for skin integrity issues, was not updated and no new care plan was initiated related to the non-pressure wound of the left great toe first identified on 12/30/2025. On 01/26/2026, an RN documented that the resident’s left great toe was swollen, red, warm, and tender, with the toenail no longer attached and the surrounding skin off, and areas of dark discoloration around the left toes. The RN notified the skin and wound consultant CRNP, who assessed the wound the same day. The CRNP documented that neither the resident nor facility nursing staff knew when the left great toe wound first appeared or what caused it, and described the toe as having the toenail removed with a large sheet of skin peeled off the entire distal toe. The CRNP’s wound assessment identified cellulitis and a new full-thickness wound measuring 2.1 cm x 6 cm x 0.3 cm with exposed dermis and subcutaneous tissue, unattached wound edges, and moderate serosanguineous drainage, though the resident denied pain. The CRNP cleansed and dressed the wound in preparation for transfer to the hospital, where the resident was later admitted for MRSA bacteremia secondary to a left foot wound and ultimately underwent a left below-knee amputation.
Failure to Maintain Secure Handrails on Resident Hallways
Penalty
Summary
Surveyors identified a deficiency related to unsecured and missing handrails on two of the facility’s four floors. The facility’s own “Policy for Facilities Maintenance Program” dated 8/12/2025 stated its purpose was to ensure a well-structured preventative maintenance program to promote safety and functionality. A work order created on 1/18/2026 by the administrator documented that handrails on the second floor needed attention and were assigned a high priority. Despite this, observations on 2/17/2026 and 2/20/2026 showed approximately a twelve-foot section of handrails on the second floor detached and unsecured from the wall. Further observation on the third floor showed an additional approximately five-foot section of unsecured and missing handrails. A CMA reported in interview that the handrails had not been repaired for several months and described them as a safety hazard. The Resident Council President stated the facility was aware the handrails had not been repaired for several months and explained that some residents depend on securing their hands on the handrails for safety. The Maintenance Director reported noticing the inoperable handrails upon being hired on 1/23/2026 and confirmed the facility was aware the second- and third-floor handrails were not secured, without knowing why repairs had not been completed. The Nursing Home Administrator acknowledged awareness that the handrails needed repair and stated that the supplier was taking too long to deliver the materials.
Failure to Obtain CPAP Order After Hospital Readmission for Respiratory Failure
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician’s recommended respiratory treatment, specifically a CPAP, was ordered and implemented for a resident readmitted from the hospital. The facility’s policy on General Physician Services states that the attending physician is responsible for managing the resident’s medical care and that care is based on the physician’s orders, including treatments and services. The resident was admitted with diagnoses of acute and chronic respiratory failure with hypoxia, obstructive sleep apnea, and obesity, and was dependent on staff for ADLs but cognitively intact with a BIMS score of 15/15. Nursing documentation shortly after admission noted diminished lung sounds bilaterally and that the resident preferred the head of the bed elevated to avoid shortness of breath, though no shortness of breath or need for supplemental oxygen was recorded at that time. The facility physician documented that the resident had presented to the ED with shortness of breath, was severely hypoxic, required BIPAP and aggressive diuresis, and was later transitioned to nasal cannula. In that same note, the physician concluded that the resident needed follow-up with pulmonary for possible PFT and possible CPAP. The resident’s care plan identified altered respiratory status related to respiratory failure and obstructive sleep apnea and directed staff to report abnormal findings to medical providers and monitor vitals. During interviews, the physician stated that, after reviewing the medical record and communicating with nursing staff, he informed nursing that the resident required a pulmonary test and a CPAP, and acknowledged that an order for CPAP should have been issued. The DON also stated there was miscommunication regarding the order and that the physician did not write it, despite facility policy requiring physician orders to be addressed in a timely manner. The resident’s cause of death was documented as congestive heart failure.
Failure to Accurately Document Turning and Repositioning on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete documentation on the Treatment Administration Record (TAR) for a resident who was readmitted to the facility and was coded as cognitively intact on a quarterly MDS. The resident had an order in January for turning and repositioning every 2 hours for wound management. Review of the January TAR showed multiple instances where this ordered intervention was not signed as completed, specifically on 01/02/2026 at 4:00 AM and 6:00 AM, 01/06/2026 at 6:00 PM, 01/10/2026 at 6:00 PM, and 01/28/2026 at 6:00 PM. The resident’s care plan dated 02/01/2026 included interventions to encourage or assist the resident to turn and reposition and to ensure the resident was turned and repositioned. During interviews, the resident reported having concerns in the past about not being turned and repositioned every 2 hours, although they stated that this had improved. An LPN and an RN who provided care to the resident each stated that they did turn and reposition the resident every 2 hours during their shifts, but both acknowledged they forgot to document these interventions on the TAR, with the LPN attributing this to getting busy with another resident. The DON confirmed that staff did reposition the resident every 2 hours but did not sign the TAR, and stated that staff were expected to document when treatments or interventions were completed. The Administrator also stated that the expectation was to document at the time of care so it would not be missed.
Persistent Urine Odors Throughout Facility
Penalty
Summary
The facility failed to maintain a sanitary and comfortable environment, as persistent strong odors of urine were observed throughout multiple resident care floors and common areas. On 12/04/2025 at 7:30 AM, the surveyor detected a strong, pungent urine odor in the main lobby on the ground floor, and the odor was consistently present in the hallways of floors G, 1, and 3. During an interview that same day, the Nursing Home Administrator and DON were made aware of the concern. A visitor stated that there is always a strong odor of urine and stool in the main lobby and on the 3rd floor during frequent visits. On 12/05/2025 at 9:20 AM, the surveyor again detected a strong urine odor in the main lobby and hallways of floors 1 and 3. Staff #13 stated that the facility uses linen for incontinence care and that carts for soiled linen and trash are kept on the floors and left in resident hallways. On 12/08/2025 at 10:05 AM, the surveyor again detected a strong urine odor in the hallways of floors 1, 2, and 3.
Infection Control Lapses in Hand Hygiene, Equipment Cleaning, Oxygen Setup, and Laundry Handling
Penalty
Summary
The facility failed to use appropriate infection control practices during resident care and medication administration. During breakfast tray collection, a GNA entered and exited five resident rooms without washing or sanitizing hands. When questioned, the GNA stated this was the first time they had heard of that expectation. The ADON/IP later stated that proper hand hygiene is expected when entering and exiting resident rooms, especially after direct contact with residents and their personal items, and that staff are trained and observed on hand hygiene multiple times a year. During medication administration, a CMA retrieved a resident’s blood pressure with a manual cuff and did not disinfect the cuff afterward, and also did not wash or sanitize hands after completing medication administration. The same CMA later failed to wash or sanitize hands before and after administering medication to another resident. A UM later used a portable vital sign machine, including the blood pressure cuff and pulse oximeter, for one resident and did not disinfect the equipment afterward, then used the same equipment for another resident without disinfecting it between residents. The ADON/IP acknowledged that staff were being educated on proper hand hygiene and disinfecting equipment after use. The facility also had hand sanitizer dispensers on the second floor that would not dispense sanitizer. The surveyor found three of eight dispensers unable to dispense hand sanitizer, including repeated attempts at the dispenser outside one resident room. Facility staff reported that some dispensers were older models without refills, some needed battery replacement, and no housekeeping staff had reported the inoperable dispensers. In addition, a resident’s oxygen humidifier bottle and tubing were observed in use without dates on either item, and the staff member responsible for the resident confirmed the items were undated. The laundry processing room was also observed in an unsanitary condition. The room was odorous, and loose, unbagged resident personal garments and linens, along with facility linens, were scattered on the floor, on top of laundry hampers, and on top of an unused washing machine. Multiple pieces of linen were visibly soiled with brown, red, and yellow stains, and the Director of Housekeeping confirmed the observations.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to provide residents with respect and dignity by not requiring staff to knock or ask permission before entering resident rooms. During breakfast tray collection on the first floor, a GNA entered rooms 101, 102, 103, 105, and 106 without knocking or asking permission to enter prior to going into the rooms. When the surveyor addressed the concern with the GNA, the GNA had no response. The ADON later stated that staff are expected to knock on the resident's door and ask permission before entering a resident's room and that staff have been educated on that topic.
Unclean bathing areas and damaged resident environments
Penalty
Summary
The facility failed to maintain a clean, sanitary bathing environment and a homelike environment in multiple resident areas. During observation, Resident #3’s room had wall damage extending across the length of the window area, with water marks, brown staining, chipped paint and wall material, rust-colored areas, and a bubbled appearance. In Resident #43’s room, surveyors observed a spackled unfinished section of ceiling above the bed, black marks on the wall, chipped paint, and bathroom concerns including a mirror with dark worn areas, a tilted and loosely affixed light fixture that only partially lit, peeling paint below the air vent, and an air vent with debris and rust-colored spots. Additional observations in Resident #32’s bathroom showed several damaged ceiling tiles with a stained brown appearance, an air vent with extensive rust-colored appearance, rust-colored spots on the ceiling grid, a lifted ceiling tile, an uncovered light fixture with two exposed bulbs, a mirror with dark gray worn areas, a hand soap dispenser with pooled liquid and debris in the catch piece and splattered debris on its surface, chipped wall paint near the dispenser, a toilet without a tank cover, wet toilet paper on the toilet seat trailing into the bowl, and red matter on the bathroom light switch. Surveyors also observed a several-foot-long crack where the second-floor ceiling connected with a lower area of the ceiling near the elevator and nursing station. In the shared first-floor shower room, a resident expressed concerns about cleanliness. Surveyors observed a used disposable razor on a shower bed with brown stains, a broken toilet wrapped in a plastic garbage bag, a used face mask on the floor, equipment blocking part of the entryway, broken baseboard tile, and gray debris on the shower floor. On follow-up observation, the used face mask remained on the floor, two used disposable razors and other used patient care items were on the shower bed, the mattress still had visible brown stains, used Band-Aids were on the floor, and a pile of gray debris remained in the shower area.
Verbal Threat to Alter Resident’s Food
Penalty
Summary
The facility failed to ensure that a resident was free from verbal abuse when a kitchen employee verbally threatened to alter the resident’s food during a dispute. The resident later stated that the staff member said, "I could be a ruthless motherfucker and I can put something into your food," and another resident who was present reported hearing the threat and corroborated the allegation. The incident was reported to the State Agency, and the facility’s investigation reviewed the resident interviews and time clock records confirming the employee was present on the day of the event. The investigation substantiated the allegation of abuse.
Missing Ombudsman and Bed Hold Transfer/Discharge Notifications
Penalty
Summary
The facility failed to maintain and provide documentation of required Ombudsman notifications related to resident transfers and discharges, and failed to provide written notification of hospital transfer and the facility’s bed hold policy to a resident’s representative. This was identified for 4 of 7 residents reviewed for transfers and discharge, including Residents #2, #11, #110, and #112. The report defines bed hold as holding or reserving a resident’s bed while the resident is absent from the facility for therapeutic leave or hospitalization. Surveyors requested documentation for the facility’s notification to the Ombudsman regarding the October 2025 hospitalizations of Residents #2 and #11, but Staff #3 stated the facility was unable to produce the required Ombudsman notification list for October 2025. Review of Resident #112’s record showed the resident was discharged home, with no documentation that the local Ombudsman was informed of the discharge. Review of Resident #110’s record showed the resident was transferred to the hospital due to abnormal lab values, but there was no documentation that the resident representative received written notification of the transfer and bed hold policy, and no documentation that the local Ombudsman was informed of the transfer. Social Worker #11 stated it was their responsibility to email the Ombudsman the transfers and discharges monthly and acknowledged they had not sent the emails consistently every month.
Failure to Document Delivery of Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide the resident and/or resident representative with a written summary of the baseline care plan for two residents, Resident #110 and Resident #112. Resident #112 was admitted from the hospital for hyperglycemic management and physical and occupational therapy, and the record showed a care conference sign-in sheet with the resident representatives, SW #11, and the DOR #20 in attendance. However, the electronic medical record did not contain documentation that the resident and/or resident representatives received a copy of the written summary of the baseline care plan. Resident #110 was admitted to the facility and had a Care Conference note that discussed the resident’s plan of care, but the record also lacked documentation showing that the resident and/or resident representative received a copy of the written summary of the baseline care plan. During interview, SW #11 stated that the baseline care plan should be completed within 48 hours of admission by the interdisciplinary team and reviewed during the initial care plan meeting within 7 days, with documentation of the meeting, medication review, and receipt of the written summary in the medical record. When asked, SW #11 confirmed there was no documentation to verify that either resident or their representative received the written summary.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure comprehensive person-centered care plans were developed and implemented for 2 residents reviewed during the annual survey. For one resident, the record showed a physician note indicating palliative care status with comfort care, and a nursing note stating the resident remained on palliative care with an order for no weights. The resident’s MOLST identified DNR option B and included no intubation, no blood, no hospital, no medical tests, no tube feed, and no dialysis. However, the care plan only addressed code status and strong support system, with a goal that the resident’s code status would be honored, and did not include a person-centered palliative care plan. For the second resident, the record showed admission from the hospital for hyperglycemic management and PT/OT with a plan to return to the community/home. The resident’s care plan, created after admission, did not include a person-centered discharge planning care plan to assess and meet the resident’s potential needs. During interview, the Social Worker stated discharge planning is discussed during the initial care plan meeting within 7 days of admission and during quarterly care plan meetings, and that discharge planning should be included in the resident’s care plan.
Care Planning Meetings Not Held or Properly Documented; Care Plans Not Updated
Penalty
Summary
The facility failed to ensure residents and/or their resident representatives had the opportunity to participate in care planning meetings with the interdisciplinary team, failed to hold quarterly care plan meetings for a resident, and failed to keep care plans accurate and revised when resident conditions changed. For two residents, care conference sign-in sheets showed only the resident representative, Social Worker, and Director of Rehabilitation were present, and the sheets did not include the resident or identify participation by other IDT members. The Social Worker stated that nursing, activities, dietary, rehabilitation, and other disciplines should participate, but also acknowledged that activities had been absent due to leave, nursing attended only occasionally, and dietary did not attend meetings. The Social Worker confirmed that the complete IDT would allow the resident and resident representative to participate in the care planning process and have questions and concerns addressed. For another resident, the record showed quarterly care plan meetings were not held from one period to another and were only documented on three dates, which staff confirmed was not supported by the resident’s record or other facility documentation. The resident also stated the facility had not been completing quarterly care plan meetings. In addition, one resident’s care plan still listed hospice-related interventions even though the resident had been discharged from hospice, and another resident’s care plan still listed full code status even though the Maryland MOLST form indicated No CPR, option A-2. The DON confirmed both care plans were incorrect.
Unsecured Housekeeping Carts with Cleaning Chemicals
Penalty
Summary
The facility failed to maintain a resident environment free of accident hazards when two of four housekeeping carts observed during the annual survey were left unattended and unlocked with containers of cleaning chemicals inside. During observation rounds, one housekeeping cart on the ground level and another on the second floor were both found unsecured. During interview, staff #13 confirmed that both carts were unlocked because the locks were broken and stated that all housekeeping carts should be locked at all times to prevent residents from getting into them.
Failure to Follow Tracheostomy and Oxygen Orders
Penalty
Summary
The facility failed to follow medical orders for respiratory care for a resident with a tracheostomy who was ordered to receive oxygen via trach at 8 liters per minute, trach care every shift and as needed, humidification, and to have the same size trach and one size smaller at the bedside at all times. During the initial observation, the resident was seen receiving oxygen through trach tubing that had an unclean appearance with orange and brown crusted substance and debris, and the resident’s gown also had debris present. The humidification bottle attached to the oxygen delivery system was observed empty and dry while oxygen was being delivered by a concentrator set at 8 liters per minute. The resident told the surveyor that the tubing was dirty, that staff did not have the things needed to care for the trach, that the trach was not being cleaned, and that the humidification water had been empty for days. The resident also reported asking for a transfer to another facility and stated they could not walk because the facility did not have portable oxygen. A wheelchair was observed in the room, but no portable oxygen equipment was present. The assigned LPN acknowledged needing to find trach supplies, and the Administrator observed the concerns and stated they would be addressed. Record review showed active orders for trach care, continuous oxygen at 8 liters via tracheostomy, humidification tubing and humidifier changes every 7 days and as needed, and emergency trach supplies at the bedside. Surveyors found only a size 7 spare trach at the bedside even though the resident’s trach was size 8, and no spare size 8 was present until the DON retrieved one from the supply room. On a later observation, the oxygen concentrator was set at 5 liters per minute instead of the ordered 8 liters, and the resident’s respiratory tubing and attached bag were lying directly on the floor.
Inadequate Staffing and Delayed Resident Assistance on Second Floor
Penalty
Summary
The facility failed to ensure adequate staffing on the second floor to meet resident needs and to have a licensed nurse in charge on each shift. During the initial tour, the second floor was staffed with one LPN, two GNAs, and a unit manager listed for the day shift, but the unit manager was not yet present when the surveyor interviewed the LPN early that morning. At the same time, the surveyor observed multiple resident care needs that were not immediately addressed, including two urinals containing yellow liquid on a resident’s over-bed table next to drinking water, a housekeeping room left open with cleaning chemicals inside, and a resident calling out from the hallway asking to be gotten out of bed because they had been in bed too long. Additional observations showed further unmet needs on the unit while staff were occupied passing breakfast trays. A resident’s PPE container was empty and the resident’s urinal was three-quarters full and hanging on the side of the bed. Another resident was sitting diagonally on the bed and stated their wheelchair was out of reach, with the wheelchair observed near the room door until staff assisted after surveyor intervention. A different resident was standing in the doorway in an incontinence brief asking for help getting dressed. Later, a resident reported there was not a lot of staff on each floor, and a family member stated staff sometimes responded and sometimes did not because they were short staffed.
Failure to Document Offer of Advance Directives
Penalty
Summary
Facility staff failed to ensure documentation of attempts made to offer advance directives for Resident #43. Review of the resident’s medical record found no documentation that advance directives had been offered. The facility’s general admission packet included advance directive information for residents, but the record for this resident did not contain documentation showing that the information was offered or recorded. During interviews, the Administrator stated that Staff #11 had been the facility Social Worker for the past six months. The Director of Social Work reported that advance directives are offered upon admission and that the offering is documented in the resident’s baseline care plan and regular care plan, but later confirmed there was nothing documented showing advance directives were offered to Resident #43. The Hospital Liaison stated residents receive the admission packet upon admission and advance directive information is given at that time, but the offering was not documented by admissions staff. The Administrator later stated the expectation was for the Social Worker to document the offering of advance directives.
Failure to Notify Physician and Resident Representative of Change in Condition and Incident
Penalty
Summary
The facility failed to notify the physician and the resident's representative of a significant change in condition and an incident that potentially required physician intervention. Specifically, a resident had an abnormally high white blood cell (WBC) count, which was not reported to the physician or the resident's representative, and no change of condition report was initiated. Additionally, the resident, who was on an NPO (nothing by mouth) diet due to difficulty swallowing, was found with a grape ice pop in hand and a large piece in the mouth. This incident was not documented as a change in condition or incident, and neither the physician, nurse practitioner, nor the resident representative was notified. A review of the facility's policies indicated that nurses are responsible for reviewing and reporting abnormal lab results and significant changes in condition to the appropriate parties, including the physician and resident representative. The Director of Nursing confirmed that these notifications and required documentation were not completed for the resident in question. The failure to follow established protocols for notification and documentation led to the deficiency identified during the complaint survey.
Failure to Address Abnormal Lab Result and Monitor NPO Resident After Oral Intake
Penalty
Summary
The facility failed to address an abnormal laboratory result and did not monitor a resident for signs of aspiration following an incident that may have required physician intervention. Specifically, a resident with a history of difficulty swallowing and who was on an NPO (nothing by mouth) diet was found with a grape ice pop in their hand and a large piece in their mouth. Despite this, there was no documentation of a change in the resident's condition or initiation of monitoring for aspiration. Additionally, the resident's medical record showed an abnormally high white blood cell (WBC) count, which is significant for identifying infection or inflammation, but the facility did not document any response to this abnormal result or a change in the resident's condition. The lack of documentation and monitoring occurred despite the resident's known risk factors and the presence of clinical indicators that warranted further assessment.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deer's Head Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Wicomico Nursing Home | 1.3 mi | ★★★★★ | 13 | 0 |
| Bay Harbor Post Acute Healthcare Center | 1.5 mi | ★★★★★ | 15 | 2 |
| Delmar Nursing & Rehabilitation Center | 6.5 mi | ★★★★★ | 4 | 0 |
| Manokin Nursing And Rehab | 12 mi | ★★★★★ | 44 | 2 |
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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.