Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bay Harbor Post Acute Healthcare Center during CMS and state inspections, most recent first.
A resident was readmitted from the hospital, but the receiving RN did not enter the new med orders into the EHR. Only acetaminophen was on the MAR, while Eliquis and other ordered meds were missing. The resident later had leg pain, the missing anticoagulant doses were discovered, and the resident developed a clot requiring a thrombectomy.
Failure to supervise smoking and wheelchair use: Surveyors observed residents sharing cigarettes in the smoking area despite a policy prohibiting sharing, and a smoking aide admitted seeing this happen many times without intervening. A resident with a BIMS of 15 and quadriplegia reported smoking outside and asking other residents for cigarettes, while staff and the DON acknowledged the resident was not on the current smoker list before surveyor intervention. Surveyors also observed ambulatory residents pushing wheelchair-bound residents without footrests, including one resident who reported a fall after being pushed too fast; staff said this happened often, and the DON stated residents had not been educated on safe wheelchair use.
A facility failed to keep the designated smoking area safe for residents using wheelchairs. A resident and multiple staff reported that the ramp was crooked, the surface was uneven, wheelchairs got stuck, and residents had fallen or been hit by the door, while surveyors observed an inclined ramp leading to a gazebo and uneven surface areas.
A resident was subjected to verbal abuse when a staff member used abusive language while attempting to bring the resident inside from a smoking area. Witnesses reported that the staff member told the resident to come inside, sit down, and shut up, and the staff member later confirmed having a verbal exchange with the resident and telling the resident to shut up. The facility’s internal investigation verified that this interaction constituted verbal abuse.
Staff failed to secure a deceased resident’s personal belongings, resulting in the loss of the resident’s cell phone. After the resident’s death, multiple GNAs observed the phone in the room on different shifts, with one placing it in a bag left in the room rather than in a secure location. Another staff member reported that belongings are typically packed, labeled, and kept behind the nurse’s station, but also acknowledged there was no secure storage area for items awaiting family pickup. When the family arrived to collect belongings, the phone and charger were missing and could not be located despite a search, leading to a citation for misappropriation of property.
Nursing staff failed to meet professional standards when a CMA administered nighttime medications intended for a discharged resident to that resident’s former roommate without verifying identity or discharge status, as documented in the medical record and facility investigation. In a separate incident, an RN treated a resident’s hypoglycemic episode with Glucagon and documented that an on-call provider ordered a repeat glucose check and possible second dose, but no corresponding Glucagon order or follow-up fingerstick result was entered in the EHR. Additionally, staff reported performing ostomy appliance changes for a resident and stated this care was documented on the TAR, yet review of the TAR and EHR showed no documentation that ostomy care was provided despite an existing order for colostomy appliance care.
A medication administration error occurred when a resident was given Gabapentin, an anticonvulsant, without any active or discontinued order for the drug and without a documented clinical indication. After receiving the medication, the resident experienced dizziness. The DON later confirmed that the Gabapentin dose had been intended for a different resident, resulting in the wrong resident receiving an unprescribed medication.
Surveyors found that staff failed to serve meals according to printed meal tickets for two residents during a lunch service. One resident, who reported disliking most facility food and relying on milk as the only item they enjoyed, did not receive the 8 oz of whole milk listed on their ticket, a fact confirmed by the Regional Food Service Director. Another resident was served mashed potatoes instead of the pasta specified on their ticket. The Food Service Director stated that the end-of-line employee is responsible for ensuring that what is served matches the meal ticket and acknowledged that residents are to receive the items indicated.
A resident's room was observed with a nightstand drawer front detached and placed inside the drawer, showing the facility failed to maintain a homelike environment. The DON was shown the broken drawer and said they would take care of it, and the drawer was later repaired after surveyor intervention.
A resident was transferred to the hospital, but the facility did not provide the resident or representative with written discharge documentation, including the reason for transfer or bed-hold information. The DON stated the facility notifies residents and families verbally, but confirmed there was no evidence of written notification or bed-hold policy provided.
Two residents had inaccurate MDS assessments. One resident’s MDS did not indicate antipsychotic use even though MARs showed daily Olanzapine, and another resident’s admission MDS incorrectly marked no pressure ulcer/injury despite documentation of a Stage 3 pressure ulcer on admission. The MDS Coordinator acknowledged the errors during interview.
Failure to Provide Scheduled Showers to Dependent Residents: Two dependent residents reported not receiving showers as scheduled. Records showed both residents were supposed to receive regular showers, but shower sheets repeatedly documented refusals, including entries made by an STNA who was off duty or not assigned to the unit. The STNA confirmed he did not offer the showers and instead marked them as refused, and the DON confirmed inconsistencies in the documentation.
A facility failed to administer medications according to orders and minimum standards of care. One resident was given a former roommate’s nighttime medication after a CMA did not verify identity or admission status, and another resident had multiple late HumaLOG insulin doses outside the expected time window. The DON confirmed insulin was expected to be given within one hour of the scheduled time, and the resident reported that insulin seemed to be administered late.
A resident with an active Foley catheter order for routine changes every 28 days reported the catheter was not being changed as often as required. Record review showed the catheter was documented as changed by a wound care nurse, but the nurse later stated she had not changed any resident's Foley in April and confirmed she marked the task complete without actually changing it.
A resident receiving dialysis did not have an active dialysis order documented in the record. During record review, no active order was found, and the DON stated that residents receiving dialysis are expected to have active dialysis orders in place. The concern was later discussed with the DON and NHA.
Missing Annual Performance Review for a GNA. Review of personnel files found that one GNA did not have a yearly performance evaluation in the file, and the NHA stated she was unable to locate it.
Failure to Provide Routine Dental Services: Two residents reviewed for dental care did not receive routine dental services. One resident reported an unclear dental follow-up history and had no dental notes or evals in the record, while the DON confirmed no dental visit since 2024 despite eligibility for health drive services. Another resident, who reported wearing dentures and not seeing a dentist for about 2 years, was observed with a chipped tooth and also had no dental evals documented beyond the admission oral assessment.
Facility nursing staff falsely documented medication administration when a CMA gave a resident medications prescribed for another resident after failing to verify identity and admission status. The facility also did not document repositioning for a resident with wounds who required substantial assistance with rolling and was reportedly turned every two hours, with staff stating the turning was not documented in the EHR task section.
Failure to follow required infection control practices was observed for multiple residents. Staff provided direct care to residents on EBP without wearing gowns, including trach care, a blood glucose check, and a bed bath, and one staff member stated nobody uses the PPE. A resident with active C. diff had the wrong precaution sign posted as EBP instead of Contact Precautions, and a visitor was observed wearing gloves but not a gown while in the room.
Multiple incidents of alleged abuse, neglect, and injury were not reported or investigated in accordance with regulatory requirements. Staff were informed of allegations involving physical and sexual abuse, as well as injuries of unknown origin, but failed to notify the SSA within the required timeframe or submit follow-up investigation reports. These lapses involved residents with both intact and impaired cognition and included both staff-to-resident and resident-to-resident incidents.
Multiple allegations of abuse, including physical, sexual, and verbal incidents involving several residents, were not thoroughly investigated by facility staff. In each case, required steps such as suspending accused staff, conducting skin or trauma assessments, obtaining written statements, and interviewing all relevant parties were not completed, despite the facility's policies mandating comprehensive investigations.
Over a nine-month period, the facility did not adequately address repeated Resident Council concerns about staffing shortages and delayed call light responses. Residents reported long waits for assistance, especially on weekends and overnight shifts, and staff sometimes turned off call lights before needs were met. Observations confirmed delayed responses, and interviews with staff and leadership revealed a lack of clear policies or documentation of corrective actions.
A resident dependent on staff for toileting was not provided timely incontinence care before attending a group activity, despite requests from both the resident and their representative. Staff communicated that providing care would prevent the resident from attending the activity, resulting in the resident attending while soiled. The facility did not thoroughly investigate the grievance or communicate resolution efforts to those involved. Additionally, multiple residents and the Resident Council reported ongoing delays in call bell response over several months, with incomplete investigations and lack of follow-up or resolution documentation.
The facility did not follow its abuse prevention and reporting policies, failing to notify law enforcement and the ombudsman about multiple allegations of abuse, neglect, and injuries of unknown origin. Investigations into these incidents were incomplete, lacking required interviews and documentation from residents, staff, and witnesses. Leadership confirmed that expected procedures were not followed, and several cases showed a pattern of noncompliance with required reporting and investigation protocols.
Staff failed to consistently follow infection control protocols, including enhanced barrier precautions during wound care for a resident with MRSA and a central line, and proper hand hygiene and glove use during catheter care for two residents with indwelling catheters. Observations revealed that staff did not use required PPE, did not sanitize surfaces or use barriers, and did not change gloves or perform hand hygiene at appropriate times, contrary to facility policy.
Staff failed to promptly assist a resident with incontinence care, resulting in the resident attending a church service in a soiled brief after being told that receiving care would prevent participation in the activity. Additionally, a staff member entered a shared room without knocking or announcing herself, contrary to facility policy. Leadership confirmed that these actions did not meet expectations for resident dignity and privacy.
Two residents with severe cognitive impairment and behavioral issues were involved in a physical altercation over a pillow, resulting in a skin tear to one resident's forearm. An LPN witnessed the incident and intervened, but the facility failed to prevent the abuse as required by policy.
A resident with hemiplegia and muscle atrophy did not receive physical therapy as frequently as ordered by the physician, with two scheduled sessions missed in one week and no documentation provided to explain the absences. Interviews with the DOR and PTA confirmed the lack of documentation and communication regarding the missed therapy, which was not in accordance with facility policy or physician orders.
Three residents did not have complete or accurate medical records, including missing orders for catheter care, absent documentation of showers and ADLs, and lost paper records for personal care. Staff and administration confirmed that all care, including refusals and scheduled tasks, should be documented in the medical record.
Surveyors found deficiencies in food storage and temperature monitoring at the facility. Observations revealed expired, unlabeled, and improperly stored food items in the medication room and clean utility room refrigerators, along with incomplete temperature logs. In the kitchen, various food items were unlabeled and undated, and temperature logs for the freezer and dishwasher were not maintained. The assistant manager confirmed these findings and acknowledged the expectations for proper labeling and temperature recording.
The facility failed to maintain a clean and safe environment, with surveyors observing unsanitary conditions such as dried stool, strong urine odors, and overflowing trash in resident rooms. Residents reported unaddressed concerns about potential mold in the dining room, and missing light bulbs and dirty toilet seats were noted. Housekeeping duties were not consistently performed, and the administrator was unaware of some issues.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident lacked an updated activities calendar, another did not have a specific care plan for nutrition despite suspected weight loss, and a third resident's care plan was missing essential communication and respiratory care details. Staff interviews confirmed these oversights.
The facility failed to implement physician orders and maintain proper documentation, affecting several residents. A resident with a PEG tube lacked management orders, while another's vital signs were inconsistently recorded. A resident's wound care was not documented, and another experienced significant weight loss without a care plan. Medication administration was delayed for two residents, impacting pain management. Weekly weight checks for a resident were not completed as ordered.
The facility failed to ensure monthly Medication Regimen Reviews (MRR) by a licensed pharmacist for three residents, leading to deficiencies in medication management. A resident had an incomplete physician order for Phenobarbital, risking incorrect dosage, while two other residents did not have MRRs conducted for several months. The DON acknowledged the oversight, and these issues were discussed with the administration team.
The facility failed to maintain a sanitary environment, with linen found on floors in multiple units and unsanitary conditions in a clean utility room. Maintenance issues included missing wallpaper and a damaged metal box. The DON confirmed these findings, and the NHA acknowledged challenges in addressing maintenance concerns due to ongoing renovations.
The facility failed to maintain resident dignity and proper care, as observed in several incidents. A resident's transfer was delayed due to a malfunctioning Hoyer lift, resulting in the resident bumping against a raised grab bar. Other issues included a resident with an uncovered Foley catheter bag, a resident with mucous secretions on their gown, and another with full and empty urinals on their bedside table. These deficiencies were acknowledged by the Director of Nursing.
The facility failed to ensure call bells were accessible for residents on Unit 4, with instances of call bells being out of reach or improperly placed. Additionally, the facility did not schedule a necessary follow-up orthopedic appointment for a resident, failing to document the appointment, transportation arrangements, or family contact.
The facility did not promptly address the resident council's recommendations on issues of resident care and life. Interviews with residents and staff, along with a review of council meeting minutes, revealed that 20 issues were consistently identified over several months, with most marked as 'Still an issue.' The DON and administrator were informed of these findings.
Facility staff failed to assess residents for advance directives and did not offer assistance with creating them. Six residents were not assessed or informed about their rights to have an advance directive, nor were they provided with written materials. The facility's policy requires inquiries and documentation of offers to assist residents, but no evidence was found to show these actions were taken.
The facility failed to address a resident's grievance regarding a missing jacket, with no follow-up or grievance filed. During a resident council meeting, multiple residents were unaware of the grievance process and feared reprisal. The Administrator could not provide documentation of addressed grievances, and ongoing issues were documented in council minutes.
The facility failed to meet professional standards of care, including not scheduling a follow-up appointment for a resident, lacking physician orders for PEG tube management, incomplete vital sign documentation for another resident, and discrepancies in narcotic counts. Additionally, discontinued controlled medications were not destroyed immediately as per policy.
The facility failed to ensure CNAs completed a state-approved GNA training program within four months of employment, affecting seven CNAs. The administrator was unaware of the four-month requirement, believing CNAs had 12 months to obtain certification. Additionally, the HR Director missed the expiration of a CNA's certification, assuming it was still active.
The facility failed to serve meals according to residents' menu tickets, as observed during a survey. Several residents did not receive the items listed on their meal tickets due to the kitchen running out of certain items. During a lunch tray line observation, it was noted that the facility ran out of several menu items, leading to substitutions not indicated on the meal tickets.
The facility failed to maintain food at an appetizing temperature during a lunch service. Due to a shortage of hot plates, the last 16 trays were delivered without proper temperature control. A test tray showed significant temperature drops, resulting in unpalatable food and room temperature coffee.
The facility failed to provide suitable and nourishing alternative meals and snacks for residents wishing to eat at non-traditional times. During a resident council meeting, all attendees reported issues with the availability and delivery of bedtime snacks, which were often unlabeled and lacked variety. A resident with special dietary needs also noted that these needs were not met. Staff interviews confirmed that snacks were sent in bulk and unlabeled, and the Senior Director of Operations stated this was standard practice.
The facility failed to document that five GNAs received screening, education, and the offering of the COVID-19 vaccination. A review of their records showed no documentation of these procedures. The IP confirmed the absence of such documentation during an interview.
The facility failed to regularly inspect bed frames, mattresses, and bed rails for potential entrapment risks, affecting five residents. Observations revealed that these residents had quarter-length bed rails raised on their beds. The facility's policy required routine inspections, but interviews with the DON and the Nursing Home Administrator confirmed that maintenance did not regularly check for entrapment risks, leading to the deficiency.
The facility failed to notify responsible parties of two residents about significant medical changes. One resident was transferred to the hospital without family notification, and another had a medication discontinued without informing the responsible party. These incidents highlight lapses in the facility's communication process.
A GNA in an LTC facility verbally threatened a resident after being physically assaulted by the resident. The incident was overheard by an RN, who reported it. The GNA admitted to making the remarks, and the facility's administrator confirmed the GNA was suspended and terminated. However, the Board of Nursing was not notified of the investigation results.
A facility failed to report an injury of unknown origin involving a resident to the state agency within the required two-hour timeframe. The incident was reported to an LPN by the resident, but the facility's Self Report Form was submitted late, and the DON and Administrator could not explain the delay.
Medication Orders Not Entered After Readmission
Penalty
Summary
Medication orders for a resident readmitted from a local hospital were not entered into the facility’s EHR after the resident returned to the facility shortly after midnight. RN #28 was the receiving nurse and was responsible for completing the admission, including documenting the physical assessment and entering the resident’s medication orders. The discharge summary listed acetaminophen 650 mg every 5 hours as needed, Eliquis 10 mg by mouth twice daily for 3 days, and 10 other medications, but only acetaminophen was administered. The resident’s previous orders remained on the chart, but the new admission orders were not entered. The resident later complained of leg pain, and when the resident’s daughter asked about the medications, staff discovered the admission medication orders had not been entered. The resident had been prescribed Eliquis to help prevent blood clotting, but three doses were not given because the order was missing from the EHR. The resident developed a clot and required a thrombectomy. An operative note later documented left lower extremity acute limb threatening ischemia with a recent history of left atrial thrombus and that planned outpatient oral anticoagulation had not been continued after discharge from the hospital.
Failure to supervise smoking and wheelchair use
Penalty
Summary
The facility failed to supervise and identify residents needing assistance with smoking and failed to ensure adequate supervision of residents in wheelchairs. Surveyors observed residents sharing cigarettes in the designated smoking area on multiple occasions, even though the facility smoking policy prohibited residents from sharing smoking items with another resident. A smoking aide stated that he or she was responsible for monitoring residents in the smoking area and admitted observing residents sharing cigarettes many times without intervening. The Activity Director stated that smoking monitors were trained to ensure residents followed the smoking policy and to notify nursing staff of policy violations, and the DON acknowledged awareness that residents shared cigarettes but admitted the facility did not place the smoking policy violations on an improvement plan. Resident #83 had a BIMS score of 15 and was quadriplegic. The resident record showed smoking evaluations stating the resident did not smoke, including the most recent evaluation, yet the resident told surveyors that he or she went out to smoke during the daytime and asked other residents for cigarettes because he or she did not have any. The resident stated that staff outside supervising smoking were okay with residents asking others for cigarettes, and identified the smoking supervisor as Staff #14 or another activities staff member. Staff #14 stated that he or she had seen Resident #83 smoking outside and that it was common for residents to request cigarettes from other residents. The DON stated nursing was not aware that Resident #83 had recently started smoking and that activities staff had not been provided a list of current smokers before surveyor intervention. Surveyors also observed ambulatory residents pushing wheelchair-bound residents without footrests on multiple occasions. Resident #8 reported falling because another resident was pushing the wheelchair too fast and stated that staff had been told not to push residents in wheelchairs without footrests. Surveyors observed Resident #47 pushing Resident #68 in a wheelchair without footrests, and also observed other residents pushing residents in wheelchairs in the smoking area. Staff #21 stated that residents pushing other residents in wheelchairs occurred often because staff had been trained not to push a resident in a wheelchair without footrests. The DON confirmed staff were trained not to push residents without footrests, but stated there was no evidence residents were educated on safe wheelchair use or instructed not to push other residents, and later could not find the staff education documentation.
Unsafe Smoking Area Access for Wheelchair Users
Penalty
Summary
The facility failed to ensure that the designated smoking area was safe for residents who used wheelchairs. During an interview, a resident reported that wheelchair users had difficulty accessing the smoking area because the ramp was crooked and wheelchairs got stuck, causing residents to fall. During a tour of the smoking area, surveyors observed an inclined ramp leading to a gazebo and several uneven surface areas. Staff also described ongoing access and safety problems in the smoking area. One staff member reported that residents in wheelchairs had difficulty getting over the door seal to use the ramp, that the door closed too fast, and that several residents' wheelchairs had gone off the paved pathway and resulted in falls. Another staff member reported that residents got stuck on the ramp often and had witnessed residents being hit by the door several times. The DON later acknowledged that the facility had experienced a couple of fall incidents in the smoking designated area and was made aware of the safety concerns.
Failure to Protect a Resident From Verbal Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from verbal abuse when a staff member directed abusive language toward the resident. Review of a facility-reported incident and investigation records showed that on the date in question, Staff #40 was attempting to get Resident #57 to come inside from the smoking area. When the resident stated they did not want to come inside, Staff #40 told the resident to “shut up” and come inside. A witness statement from Staff #21 documented that Staff #40 told the resident, “Just come inside, sit down, and shut up,” and the Activities Director (Staff #13) recalled being notified that Staff #40 was going back and forth with a resident and told the resident to shut up. During the facility’s investigation, the DON reported that Staff #40 confirmed having words back and forth with the resident and acknowledged stating “come inside and shut up,” and the facility verified the allegation of verbal abuse. The DON was subsequently notified that this constituted a concern related to the requirement to protect residents from all types of abuse, including verbal abuse.
Failure to Secure Deceased Resident’s Personal Belongings
Penalty
Summary
Facility staff failed to protect a deceased resident’s personal belongings, specifically the resident’s cell phone, from misappropriation. The resident died on 03/17/26, and documentation noted that the family would come to collect the resident’s belongings. When the family arrived to pick up the belongings, the resident’s cell phone was missing. The resident’s daughter reported the missing phone to the Administrator on 03/20/26, and staff searched the laundry and the resident’s room but were unable to locate it. A nurse supervisor documented that when the phone could not be found, the police were notified. Multiple staff statements showed that the resident’s cell phone had been seen in the room after the resident’s death but was not secured. One GNA reported seeing the phone on 03/18/26 and placing it in a green Bay Harbor bag that was left in the room, even though the resident had passed and could no longer use the phone. Another GNA reported seeing the phone on the bedside table during the 11 pm–7 am shift on 03/17/26. The RN Unit Manager documented that when the family went into the room, there was no phone or charger present. One GNA stated that when a resident passes, belongings are usually packed, labeled, and kept behind the nurse’s station for a day or two before housekeeping takes them downstairs, and acknowledged there was no secure place for belongings until family retrieval. Another GNA stated they did not handle the belongings because they were not instructed to do so and were unsure of the policy. The cell phone was never located, and the facility was cited for misappropriation of property.
Medication Errors, Incomplete Hypoglycemia Documentation, and Missing Ostomy Care Records
Penalty
Summary
Nursing staff failed to meet professional standards by incorrectly administering medications and not properly identifying a resident prior to administration. A certified medication aide (CMA) gave nighttime medications intended for a discharged resident to that resident’s former roommate. The medical record documented a change in condition note stating that the roommate received the other resident’s nighttime medications, although no abnormal signs or symptoms were observed and the provider was notified. The facility’s internal investigation identified that the CMA did not verify the resident’s identity and did not confirm the discharged resident’s status before administering the medications, despite existing training that requires verification of unit census and resident identity and removal of medications from the cart after discharge. Nursing staff also failed to adhere to standards of practice regarding documentation of verbal orders and follow-up care during a hypoglycemic episode. A resident was noted to be difficult to arouse with a fingerstick blood glucose of 50 mg/dl, and an RN administered Glucagon to the resident’s left thigh. The RN documented that an on-call provider was notified and that an order was received to recheck the glucose in 10 minutes, give another dose of Glucagon, and notify the provider of the results. However, the electronic health record contained no written medication order for two doses of Glucagon and no documented follow-up fingerstick result, despite the RN later stating that the resident received one dose of Glucagon and that the follow-up fingerstick was 88 mg/dl. In addition, nursing staff failed to document ostomy care for a resident with an ostomy. An RN reported that they had wound care training, performed ostomy appliance changes as needed, and that this care was documented on the treatment administration record (TAR). Review of the TAR for the relevant month showed no documentation that the resident’s ostomy appliance was changed or that ostomy care was provided. Another RN stated that ostomy care should be ordered and documented on the TAR and signed when completed, and the wound care nurse was unable to locate documentation in the electronic health record verifying that the ordered colostomy appliance care was actually provided.
Medication Error: Unprescribed Gabapentin Administered to Resident
Penalty
Summary
A medication administration deficiency occurred when Gabapentin, an anticonvulsant, was given to Resident #54 without a clinical indication. A complaint was made alleging that the resident received Gabapentin inappropriately, and subsequent record review showed that the resident had no active or discontinued order for this medication. Documentation further revealed that the resident experienced side effects, including dizziness, after the administration of Gabapentin. During an interview, the Director of Nursing confirmed that a medication error had occurred and clarified that the Gabapentin dose administered to Resident #54 had been intended for a different resident. These findings demonstrate that the resident received a medication not prescribed for them and without a documented clinical indication, resulting in adverse effects.
Failure to Serve Meals According to Printed Meal Tickets
Penalty
Summary
Surveyors identified a deficiency in meal service when residents were not served food and beverages according to their printed meal tickets. During a lunch observation, one resident’s tray lacked the 8 oz of whole milk specified on the meal ticket, and the resident stated they did not like the facility’s food and looked forward to milk as the only item they enjoyed, confirming they had not received it. The Regional Food Service Director, present during this observation and interview, confirmed that milk was not served as ordered. In a separate observation minutes later, another resident was served mashed potatoes instead of pasta, which was listed on their meal ticket. The Facility Food Service Director reported that the employee at the end of the food line is responsible for ensuring that the meal ticket matches what is served and acknowledged that residents should receive what is indicated on their meal tickets. On the same day, the facility administrator was notified of these concerns, which demonstrated that the facility failed to follow residents’ meal tickets for at least two residents during the observed dining period.
Broken Nightstand Drawer in Resident Room
Penalty
Summary
The facility failed to maintain a homelike environment for Resident #83 when the resident's nightstand drawer front was found detached and placed inside the drawer during an observation of the room. The deficiency was identified after the surveyor observed the broken drawer and showed it to the DON, who stated they would take care of it. A later observation showed the drawer had been repaired after surveyor intervention.
Failure to Provide Written Transfer and Bed-Hold Notification
Penalty
Summary
The facility failed to provide the resident or representative with required written discharge documentation related to a transfer to the hospital, including the reason for transfer and bed-hold notification. Resident #230 was sent to the hospital on 3/15/2026, and a nursing note documented that the resident's sibling was notified. However, the resident's profile identified the resident as their own representative. During record review and interview with the DON, the surveyor requested evidence that written discharge notification and bed-hold information had been provided to the resident or representative. The DON stated that the facility notifies residents and families verbally of transfers, but on further review confirmed that there was no written reason for transfer to the hospital and no evidence that the bed-hold policy was provided to the resident or representative.
Inaccurate MDS Assessments for Antipsychotic Use and Pressure Ulcer Status
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments accurately for 2 residents reviewed. One resident’s MDS assessment dated 3/4/2026 indicated in Section N0415 that the resident did not receive antipsychotics, but the February and March 2026 Medication Administration Records showed daily administration of Olanzapine, an antipsychotic. Another resident’s admission MDS dated 3/3/2026 indicated in Section M0100 that the resident did not have a pressure ulcer/injury, scar over a bony prominence, or non-removable dressing/device, while Section M0300 indicated a Stage 3 unhealed pressure ulcer. The resident’s admission skin screening also documented a Stage 3 pressure ulcer on admission. During interview, the MDS Coordinator stated that the antipsychotic item for the first resident was completed incorrectly and that the pressure wound item for the second resident was checked No in error.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide showers to dependent residents. Resident #243 reported that they had not had a shower in a long time and wanted to shower at least once a week. Their record showed they were scheduled for showers on Mondays and Thursdays from 3:00 PM to 11:00 PM, and the care plan indicated the resident was dependent on staff for showers, but did not show that the resident had refused showers. Review of the shower refusal documentation showed that Staff #34 signed most of the shower sheets as resident refused, including on 4/6/26, even though the staff schedule showed Staff #34 was off that day and there was no time punch for that shift. Resident #56 also reported that they had not been offered a shower for several months. Their record showed they were dependent on staff for showers and scheduled to shower on Tuesdays and Fridays. Review of the shower sheets for March and April 2026 showed refusals documented and only one shower on 3/24/26, but the care plan did not include a plan for shower refusal. The shower sheets showed Staff #34 documented refusals on all shifts even though the resident was not assigned to his unit. Staff #34 later confirmed he had not offered showers to Resident #243 or Resident #56 in April and had marked the showers as refused without offering them. The DON also reviewed the shower sheets and electronic documentation and confirmed inconsistencies in the records.
Medication Administration Errors and Late Insulin Doses
Penalty
Summary
The facility failed to administer medications in accordance with minimum standards of care for three residents during the annual survey. For one resident, a complaint investigation found that a CMA administered medication that had been prescribed for the resident’s former roommate after the roommate had already discharged. The resident was given the roommate’s nighttime medication, and the medical record documented that the resident had no abnormal signs or symptoms after the incorrect administration. The record also showed the provider was notified and ordered vital signs to be monitored every 4 hours for 12 hours. The facility’s investigation stated that the CMA did not verify the resident’s identity before giving the medication and did not verify the admission status of the resident for whom the medication had been prescribed. For another resident receiving HumaLOG sliding scale insulin before meals and at bedtime, the record review showed repeated late administrations outside the expected time window. Ten insulin doses were documented as given more than one hour after the scheduled times, including multiple late noon and evening doses. The resident stated that insulin seemed to be given late, and both an RN and the DON confirmed that insulin was expected to be administered within one hour before or after the scheduled time, with anything beyond that considered late. The DON also stated that fingerstick blood glucose checks were obtained and insulin was administered prior to meal tray delivery.
Failure to Change Foley Catheter as Ordered
Penalty
Summary
The facility failed to change a resident's Foley catheter as ordered for Resident #71, who had an active order for catheter changes every 28 days and as needed for blockage. During an interview, the resident stated that the facility did not change the Foley catheter as often as required. Record review showed the catheter was documented as changed on 4/6/2026 by Staff #39, the wound care nurse. However, when interviewed, Staff #39 stated she had not changed any resident's Foley catheter in April and confirmed that she marked the task as completed without changing the Foley. In a follow-up interview, the resident stated that no one had changed the catheter in April.
Missing Active Dialysis Order
Penalty
Summary
The facility failed to ensure complete and accurate dialysis orders were present for a resident receiving dialysis services. Record review on 04/13/2026 at 9:47 AM did not reveal an active dialysis order for Resident #223, who was the only resident reviewed for dialysis. During an interview on 04/14/2026 at 6:28 AM, the DON stated that residents receiving dialysis are expected to have active dialysis orders in place. The concern was later brought to the DON and NHA on 04/16/2026 at 10:57 AM, and they indicated that they understood.
Missing Annual Performance Review for GNA
Penalty
Summary
The facility failed to conduct yearly performance reviews at least every 12 months for 1 of 5 personnel files reviewed, specifically Staff #24, a Geriatric Nursing Assistant. A review of the personnel file on 04/15/2026 at 3:00 PM found no yearly evaluation in the file. On 04/16/2026 at 10:35 AM, the Nursing Home Administrator stated she was unable to locate it.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for 2 residents reviewed for dental care. Resident #56 reported having seen a dentist “a while ago” but was unsure when follow-up was due because the facility had not communicated with them. Review of the medical record did not reveal any dental notes or evaluations, and the DON stated that the only available documentation was an oral assessment completed at admission. The DON later confirmed that the resident had not been seen by dental services since 2024, although the resident qualified for routine dental services through health drive. Resident #9 reported previously wearing dentures and stated they had not seen a dentist for about 2 years. The surveyor observed a chipped tooth. Review of the medical record did not reveal any dental evaluations or notes, and the DON confirmed that the only oral evaluation completed was the nursing admission assessment. The DON later stated that Resident #9 had not received routine dental services and was unsure why, despite the resident qualifying for routine dental services through health drive.
False medication documentation and missing repositioning records
Penalty
Summary
Facility nursing staff falsely documented medication administration for one resident when the medication was actually given to another resident. A complaint investigation found that a CMA administered medications prescribed for a former roommate to a resident after failing to verify the resident’s identity and admission status. The resident’s record showed a change in condition note stating the roommate’s nighttime medication had been given, but the MAR did not document the incorrect administration. Review of the other resident’s record showed discharge from the facility earlier that day, yet the MAR documented administration of multiple medications at 2200, including methocarbamol, Lipitor, ropinirole, aspirin, Cymbalta, metoprolol, Protonix, Bactrim, and gabapentin. The facility also failed to document repositioning for a resident with wounds. Review of the resident’s EHR showed wounds on the right heel, right ischial area, and sacrum, and the MDS indicated the resident required substantial maximum assistance with rolling and could not independently roll from back to side and return to back in bed. Staff interviews stated residents who could not turn independently were typically repositioned every two hours, but this was not documented in the task section. A GNA stated there was no place to document the turning in PointClickCare, and an RN unit manager stated residents with wounds would be offloaded with pillows or on an air mattress, with documentation expected on the Kardex.
Failure to Follow Required Infection Control Precautions
Penalty
Summary
Failure to follow infection control practices occurred during care provided to 4 residents with Enhanced Barrier Precautions or other required precautions. Resident #14 had a tracheostomy and an EBP sign posted outside the room, but during trach care Staff #37 wore gloves and did not wear an isolation gown. Resident #196 had a PICC line and a wound vacuum device with EBP signage posted, but a Registered Nurse entered the room and performed a blood glucose check without donning a gown. Resident #83 had an active EBP order and was observed receiving a bed bath while Staff #36 did not wear the indicated gown and gloves; Staff #36 stated that nobody uses the PPE, and the resident reported staff do not wear the appropriate PPE when providing direct care. Resident #240 stated they were diagnosed with C. diff on 4/11/2026, but the signage posted outside the room indicated Enhanced Barrier Precautions rather than Contact Precautions. During the observation, a visitor was present in the room wearing gloves but not a gown while in direct contact with the resident's environment. The Infection Preventionist confirmed the resident had C. diff and stated Contact Precautions were required, with gowns and gloves for everyone entering and exiting the room, and confirmed the wrong signage had been posted until it was changed after surveyor intervention.
Failure to Timely Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or theft, and did not submit the results of investigations to the State Survey Agency (SSA) within the required timeframes for multiple residents. In several instances, staff were made aware of allegations of physical and sexual abuse, as well as injuries of unknown origin, but these were not reported to the SSA within two hours as required by facility policy and federal regulations. For example, one resident reported being physically abused by a registered nurse, and although staff notified the Director of Nursing (DON), the allegation was not reported to the SSA. Another resident alleged being pushed by a housekeeper, but the initial report to the SSA was delayed and the follow-up investigation was not submitted within five working days. Additionally, there were failures to report and investigate allegations of sexual abuse and retaliation between residents. One resident reported an incident involving another resident attempting to touch their genitals and subsequent feelings of intimidation and isolation. Staff were informed of these allegations, but the facility did not report them to the SSA as required. In another case, a resident with severely impaired cognition was found with discoloration on their arm, and while an initial report was submitted, the final investigation report was not provided to the SSA. The facility's own policy required immediate reporting of abuse allegations to the administrator and appropriate authorities, defining 'immediately' as within two hours for incidents involving abuse or serious bodily injury. Despite this, multiple incidents were either not reported, not reported timely, or not followed up with the required documentation to the SSA. These failures were identified through observation, interviews, record reviews, and policy reviews, and were determined to have caused, or were likely to cause, serious injury, harm, impairment, or death to residents.
Removal Plan
- Statements were obtained from involved residents #41, #22 and #33 by the Nurse manager.
- Resident #41, Resident #22, and Resident #33 were assessed to ensure no injuries, physical or psychological, were present by the nurse manager.
- RN #20 and Housekeeper #28 have been suspended by Regional Director of Operations.
- The administrator and director of nursing have been suspended by Regional Director of Operations.
- Statements were obtained from the accused employees #20 and #28 by Regional Nurse.
- Social Services has met with involved residents #41, #22 and #33 to address any psychosocial concerns.
- Residents #41 (allegation of physical abuse) and #33 (allegation of sexual abuse) responsible parties were made aware of the allegations by Nurse manager. Education provided for timely abuse reporting based on CMS regulation.
- Medical Directors were made aware of the allegations of physical and sexual abuse.
- Police were notified of the allegations of physical and sexual abuse. Maryland Department of Health was notified of the allegations of physical and sexual abuse.
- Medical Directors were notified of the allegations of physical and sexual abuse for residents #41 and #33.
- Ombudsman was notified of the allegations of physical and verbal abuse.
- Trauma informed evaluations completed for identified residents #41 and #33.
Failure to Thoroughly Investigate Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving four residents. In one instance, a resident with intact cognition and a history of falls reported that a registered nurse physically abused them by grabbing their head and squeezing their arm after a fall. Although staff were informed and some statements were collected, the Director of Nursing (DON) did not initiate a comprehensive investigation, did not suspend the accused nurse, and did not report the incident to the State Survey Agency as required. Witnesses were not fully interviewed, and documentation was incomplete. Another resident alleged that a housekeeper pushed them, an incident witnessed by staff. However, the facility did not perform a skin audit or trauma assessment on the resident, nor did it obtain a written statement from the resident or interview other potential witnesses. The investigation relied on a summary of staff interviews and did not include direct input from the resident or other residents in the area at the time of the incident. A third resident reported that another resident attempted to touch them inappropriately and that subsequent retaliation occurred. Despite the resident self-isolating and reporting the incident to multiple staff members, the facility did not conduct an investigation into the allegation. Additionally, an allegation of verbal abuse made by another resident was not thoroughly investigated, as the facility failed to obtain written statements from staff or residents related to the claim. These failures were contrary to the facility's own policies, which require comprehensive investigation and documentation of all abuse allegations.
Removal Plan
- Obtain statements from involved residents #41, #22 and #33
- Assess residents #41, #22, and #33 to ensure no injuries, physical or psychological, are present
- Suspend RN #20 and Housekeeper #28
- Suspend the administrator and director of nursing
- Obtain statements from the accused employees #20 and #28
- Social Services to meet with involved residents #41, #22 and #33 to address any psychosocial concerns
- Notify responsible parties of residents #41 and #33 of the allegations
- Notify police of the allegations of physical and sexual abuse
- Notify Maryland Department of Health of the allegations of physical and sexual abuse
- Notify Medical Directors of the allegations of physical and sexual abuse for residents #41 and #33
- Notify Ombudsman of the allegations of physical and verbal abuse
- Complete trauma informed evaluations for identified residents #41 and #33
- Educate all current employees regarding investigation of abuse
- Educate nurse managers and social workers on abuse investigation
Failure to Address Resident Council Concerns on Staffing and Call Light Response
Penalty
Summary
The facility failed to adequately address ongoing concerns raised by the Resident Council regarding staffing levels and call light response times over a nine-month period. Resident Council minutes repeatedly documented complaints about insufficient staff on weekends, delayed responses to call lights, and staff not assisting residents with getting up or providing care during certain shifts. Despite these recurring concerns, the facility's responses were limited to general statements, requests for more specific information, or references to individual cases, without evidence of comprehensive investigation or resolution. Documentation such as call bell audits and records of supervisory rounds or spot checks, which were cited as part of the facility's response, were not provided for review. Observations during the survey confirmed that call lights were left unanswered for extended periods, and staff sometimes turned off call lights before residents' needs were met. For example, one resident's call light remained on and flashing for a prolonged time, and the resident reported that their need was not met even after the call light was answered. Another resident waited over an hour for acetaminophen after activating their call light. Staff interviews corroborated that call lights were not always answered promptly, often due to multiple simultaneous calls and insufficient staffing. Interviews with facility leadership revealed a lack of clear policies or targets for call light response times, and there was no evidence that the concerns raised by the Resident Council were systematically addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process. The Regional Director of Operations and Regional Nurse Consultant were unable to provide documentation of corrective actions or performance improvement plans related to these issues. The facility's grievance policy required prompt investigation and resolution of complaints, but there was no documentation that this process was followed for the Resident Council's ongoing concerns.
Failure to Promptly and Consistently Resolve Resident Grievances Related to Incontinence Care and Call Bell Response
Penalty
Summary
The facility failed to ensure prompt and consistent efforts were made to resolve resident grievances, specifically in relation to incontinence care and call bell response times. In one instance, a resident with hemiplegia and hemiparesis, who was dependent on staff for toileting, experienced an episode of incontinence while preparing to attend church. The resident and their representative reported that staff informed the resident that if incontinence care was provided, the resident would not be able to attend church. As a result, the resident attended church in a soiled brief. Documentation showed that the Manager on Duty was informed of the incident well after lunch, and although the resident was eventually provided care, there was no thorough investigation or communication of the facility's efforts to resolve the grievance to the resident or their representative. Staff interviews revealed that key personnel were unaware of the grievance until much later, and statements were not collected in a timely manner. The facility also failed to address and resolve repeated grievances and concerns related to staff response to call bells, as reported by multiple residents and the Resident Council over a nine-month period. Grievance forms and Resident Council Meeting Minutes documented ongoing complaints about delayed call light responses, staff turning off call bells before needs were met, and staff being inattentive or unavailable. Investigations into these grievances were often incomplete, lacking documentation of whether actual delays occurred or what specific actions were taken. In several cases, there was no follow-up with residents or their families regarding the facility's efforts to resolve the grievances, and some grievances remained unresolved for extended periods. Observations and interviews further confirmed ongoing issues with call light response times. Residents reported waiting significant periods for assistance, and staff acknowledged challenges in responding promptly due to workload and staffing levels. Facility leadership and consultants were unable to specify targeted response times or provide evidence of systematic efforts to address the pattern of grievances. There was also no documentation that these concerns were addressed in the facility's Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its abuse prohibition and prevention policies for multiple residents, as evidenced by the lack of proper reporting and incomplete investigations into allegations of abuse, neglect, and injuries of unknown origin. In several cases, allegations made by residents or their representatives were not reported to required external agencies such as law enforcement and the ombudsman, despite facility policy mandating such notifications. For example, allegations involving rough care, physical abuse, and neglect were not communicated to the appropriate authorities, and documentation showed that notifications were either delayed or not made at all. Investigations into reported incidents were incomplete and did not follow facility policy. In multiple instances, investigation reports lacked statements from the residents who made the allegations, the staff members involved, and potential witnesses. For example, in one case, a resident alleged rough care by a GNA, but the investigation file did not include statements from the resident or the staff present during the incident. Similarly, another resident alleged that a housekeeper pushed them, but the investigation lacked statements from both the resident and the housekeeper, and there was no evidence that other residents or staff were interviewed as required by policy. Interviews with facility leadership confirmed that the expected procedures for thorough investigations and reporting were not followed. The Regional Director of Operations and the Regional Nurse Consultant acknowledged that interviews with all involved parties and timely notifications to external agencies were part of facility protocol, yet these steps were not consistently documented or performed. Additionally, review of initial reports for several other residents revealed that allegations of verbal abuse and injuries of unknown origin were not reported to required agencies, further demonstrating a pattern of noncompliance with abuse prevention and reporting policies.
Failure to Implement Infection Control Practices During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure staff consistently and correctly implemented infection control practices, specifically regarding enhanced barrier precautions (EBP) during wound care and proper catheter care and hand hygiene. During wound care for a resident with a history of MRSA infection and a central line, an LPN performed hand hygiene and donned gloves but did not wear an isolation gown as required by the facility's EBP policy. The LPN was unable to state whether a gown was necessary and noted the absence of PPE setup outside the resident's room, despite a caddy with PPE being present. The resident's care plan and physician orders clearly indicated the need for EBP, including gown and glove use during high-contact care activities such as wound care. In two separate observations of catheter care, staff did not follow proper infection control protocols. For one resident with an indwelling catheter, a GNA failed to sanitize the bedside table or use a barrier before placing supplies, did not change gloves or perform hand hygiene during the procedure, and cleaned the catheter in the incorrect direction. The GNA acknowledged not changing gloves or performing hand hygiene and stated that gloves would only be changed if they ripped or became soiled. For another resident with an indwelling catheter, a different GNA also failed to sanitize the nightstand or use a barrier, did not change gloves or perform hand hygiene after providing catheter care, and continued to handle the resident's personal items and assist with grooming while still wearing the same gloves. This GNA was unaware of the need to change gloves and perform hand hygiene at specific points during the procedure. Interviews with the Infection Preventionist, Interim DON, and Regional Director of Operations confirmed expectations that staff should follow EBP and hand hygiene protocols. However, the Infection Preventionist admitted to only occasionally observing staff during wound and catheter care, and the staff involved were either unaware of or did not adhere to the required infection control practices. The facility's own policies on EBP, hand hygiene, and catheter care were not followed during the observed care activities, leading to the identified deficiencies.
Failure to Provide Dignified Care and Respect Resident Privacy
Penalty
Summary
Facility staff failed to treat three residents with dignity and respect as required by policy. One resident, who had a history of hemiplegia, hemiparesis, chronic heart failure, and chronic pain, was dependent on staff for toileting and hygiene. On the day of the incident, the resident experienced incontinence while preparing to attend church and requested assistance with hygiene. Staff informed the resident that if incontinence care was provided, the resident would not be able to attend church, leading the resident to attend the service in a soiled brief. The Manager on Duty was not informed of the incident until after lunch, and incontinence care had still not been provided by early afternoon. Multiple interviews confirmed that the resident and their representative reported the incident, and staff acknowledged the failure to provide timely care. Additionally, the facility failed to ensure privacy and dignity for two other residents sharing a room. During an observation, a staff member entered the shared room without knocking or announcing herself, despite the facility's policy requiring staff to knock and request permission before entering any resident's room. The staff member believed that knocking was unnecessary if the door was open, a misunderstanding not supported by facility leadership or policy. Interviews with facility leadership confirmed that the expectation was for staff to always knock or announce themselves before entering, regardless of whether the door was open. These incidents demonstrate that staff did not follow established policies designed to protect resident dignity, including prompt response to requests for incontinence care and respecting privacy by knocking before entering resident rooms. The failures were confirmed through interviews with residents, their representatives, and facility staff, as well as review of facility policies and grievance documentation.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. According to facility records and staff interviews, one resident with severe cognitive impairment and a history of psychosocial well-being issues was involved in a physical altercation with their roommate, who also had severe cognitive impairment, dementia, and a history of behavioral problems including aggression and poor impulse control. The incident occurred when the aggressive resident entered the other resident's bed and began fighting over a pillow, resulting in a skin tear on the affected resident's forearm. Staff observed the altercation and noted that the aggressive resident had their fingernails in the other resident's arm during the incident. Both residents had documented histories of cognitive impairment and behavioral concerns, with care plans indicating risks for negative interactions and physical behaviors. Progress notes and staff interviews confirmed that the altercation was witnessed by an LPN, who intervened to separate the residents. The facility's policies prohibit all forms of abuse and require recognition and prevention of such incidents, but the altercation still occurred, resulting in physical harm to one resident.
Failure to Provide Therapy Services as Ordered and Document Reasons for Missed Sessions
Penalty
Summary
The facility failed to provide physical therapy (PT) services in accordance with physician orders for one resident who had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as muscle wasting and atrophy. The resident was admitted with significant deficits in activities of daily living (ADLs) and had orders for PT evaluation and treatment five times a week for 30 days, with subsequent recertifications to continue therapy at the same frequency. Documentation showed that during one week, the resident received PT only three times instead of the five times ordered, with no explanation documented for the missed sessions. Interviews with the Director of Rehabilitation and the Physical Therapy Assistant confirmed that the resident was scheduled for therapy on the missed days, but there was no documentation as to why therapy was not provided. The facility's policy required care and services to be provided and documented in accordance with physician orders and professional standards. The lack of documentation for the missed therapy sessions and absence of communication regarding the reasons for not providing therapy constituted a failure to follow physician orders and facility policy.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, as required by professional standards and facility policy. For one resident with a history of cirrhosis and ascites, who was admitted with an indwelling urinary catheter, there was no documented order for catheter care in the medical record, despite the care plan and nursing documentation indicating that catheter care was being provided every shift. Interviews with nursing staff and administration revealed that orders for catheter care should have been entered upon admission, but there was no evidence that this occurred. Another resident, admitted with hemiplegia and muscle wasting, required substantial assistance with activities of daily living (ADLs), including showering and personal hygiene. Documentation for scheduled showers was missing for two specific dates, and staff interviews confirmed that care such as showers and ADLs should be documented in the electronic record, including refusals or if the resident was not present. The interim DON and Regional Director of Operations both stated that they expected staff to document all care provided in the resident's medical record. A third resident, with diagnoses including aphagia, dysphagia, and vascular dementia, was dependent on staff for all ADLs and was noted to be resistive to care. Family concerns were raised regarding missed showers, and the DON was unable to locate shower documentation for two months. The DON confirmed that shower care was documented on paper forms during that period, but these records were missing from the resident's medical record. The interim DON reiterated that such documentation should be included in the resident's record, and the RDO expected all care to be documented.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility was found to have deficiencies in food storage and temperature monitoring practices. During an inspection, surveyors observed that the medication room and clean utility room refrigerators contained expired, unlabeled, and improperly stored food items. The medication room refrigerator was dirty, with dried food stains and sticky residues, and contained a cup of pudding with an outdated label. In the clean utility room refrigerator, there were several food items, including bologna, cheese, and milk, that were either expired, unlabeled, or opened without proper labeling. The temperature log for this refrigerator was also incomplete, lacking documentation of freezer or refrigerator temperatures. In the kitchen, similar issues were noted with food storage and labeling. The kitchen refrigerator contained various unlabeled and undated food items, such as eggs, lunch meat, raw meat, and cooked chicken. The dry storage room had prepped cereal bowls that were undated. Additionally, the kitchen freezer's temperature log had not been updated since a previous date, and the dishwasher temperature records were incomplete. The assistant manager confirmed these findings and acknowledged that the expectation was for staff to label food with preparation and discard dates and to record equipment temperatures each shift.
Inadequate Housekeeping and Maintenance in LTC Facility
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations of inadequate housekeeping and maintenance services. During the survey, a shower room was found with dried stool on the floor, and a cotton-tipped swab was left unattended in a resident's bathroom for several days. Additionally, a resident's bathroom wall was in need of painting, and another resident reported that their room had not been cleaned for two consecutive days, resulting in food and trash scattered throughout the room and a foul-smelling substance in the bathroom. Further observations revealed several rooms with strong urine odors, sticky floors, and overflowing trash cans. The main dining room had ceiling tiles with dark brown spots and wall columns with a dark black substance, which residents suspected might be mold. Despite residents voicing concerns about these issues to the administrative staff over the past four months, no action had been taken until the surveyor's visit. The survey also noted missing light bulbs, dirty toilet seats, and other unsanitary conditions in several resident rooms. The Environmental Services Director confirmed that housekeepers were responsible for cleaning the rooms daily, but the surveyor's findings indicated a lack of adherence to these duties. The facility's administrator was unaware of the missing light bulbs, highlighting a communication gap between staff and management regarding maintenance and housekeeping responsibilities.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for three residents, leading to deficiencies in addressing their specific needs. Resident #150 was not provided with an updated activities calendar, resulting in a lack of awareness about daily and special events. Despite the care plan indicating that the resident should receive a monthly activity calendar and be invited to special activities, the Life Enrichment Director confirmed that daily activity calendars were not posted in resident rooms, and the Main Events calendar was missing. Resident #116 did not have a specific care plan for nutrition or weight loss, even though the resident was receiving a nutritional supplement and had a suspected weight loss. The Registered Dietician acknowledged that a weight loss care plan should have been in place, but the weight was not confirmed, and interventions were not included in the care plan. Additionally, Resident #179 lacked a specific care plan for communication and respiratory care, with the respiratory care plan missing essential information about the tracheostomy tube. The Director of Nursing explained that the resident communicated through gestures and eye movements, with their spouse assisting in communication, but the care plan did not reflect these specifics.
Deficiencies in Implementing Physician Orders and Documentation
Penalty
Summary
The facility failed to ensure that physician's orders were implemented and completed, which affected several residents. Resident #178 was admitted with a PEG tube, but there were no documented physician orders for its management, such as flushing or dressing changes. The Director of Nursing (DON) confirmed the absence of these orders. Additionally, Resident #297's vital signs were not consistently documented as per the physician's order, which required monitoring every shift for seven days post-admission. The DON acknowledged that the nursing staff should have implemented the orders as directed. Resident #150 reported that their sacral wound dressing was not changed as ordered. The medical record confirmed that the wound care was not documented as completed on a specific evening shift, and there was no explanation for this omission. Resident #116 experienced significant weight loss without a care plan in place to address it. The Registered Dietician (RD) noted that a reweigh was requested but not completed due to an oversight, and the resident's intake was inconsistent. Medication administration issues were also identified. Resident #193 reported unmanaged pain due to delayed medication administration, and the audit revealed a pattern of late documentation for pain medications. Similarly, Resident #188, who was on comfort care, had medications documented late, which included those critical for pain management. Resident #107's weekly weight checks were not completed as ordered, and the Nurse Unit Manager could not provide an explanation for this oversight.
Failure in Conducting Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly Medication Regimen Review (MRR) for three residents, leading to deficiencies in medication management. For Resident #133, a physician order for Phenobarbital was incomplete, missing the milligram dosage, which could have resulted in the administration of an incorrect number of tablets. Despite this, a pharmacy review conducted on January 8, 2025, reported no irregularities. This indicates a failure in identifying and reporting medication-related issues. Additionally, the facility did not conduct MRRs for Resident #107 for the months of September, October, November, and December 2024. The Director of Nursing (DON) was unable to locate these reviews and acknowledged the requirement for monthly MRRs. Similarly, Resident #150's medical records showed that the pharmacy did not complete the monthly drug regimen reviews for September, October, and December 2024. These oversights were discussed with the administration team during the exit meeting on January 17, 2025.
Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a sanitary environment, as evidenced by observations on three of the four units. On multiple occasions, linen was found on the floor in various locations, including outside bathrooms and in resident rooms. The Director of Nursing confirmed these observations, and the Unit 2 & 3 Manager stated that the expectation is for staff to place soiled linen in designated carts or rooms. Additionally, a large area of missing wallpaper was observed in the Unit 2 hallway, and a metal box with a missing corner exposing rough edges was noted behind the nurses' station. The Director of Maintenance indicated that staff are expected to report maintenance concerns using an online platform, but the Nursing Home Administrator acknowledged the difficulty in addressing all maintenance issues promptly due to ongoing renovations and resource limitations. Further observations revealed unsanitary conditions in the clean utility room at Station #1, where a dark substance was noted around the faucet, and dirty items were improperly stored. The Director of Nursing verified these findings and took immediate action to clean the area. The Administrator was informed of these concerns, highlighting the facility's failure to ensure a clean and safe environment for residents, staff, and the public.
Failure to Maintain Resident Dignity and Proper Care
Penalty
Summary
The facility failed to maintain the dignity of several residents, as observed during a survey. One incident involved a resident who was being transferred using a Hoyer lift. The process was delayed due to a malfunctioning battery, requiring multiple replacements and assistance from the Maintenance Director. During the transfer, the resident was observed bumping against a raised grab bar, which should have been lowered. Additionally, the resident was noted to have a large wet area on their bottom, indicating a lack of timely incontinent care. The GNA involved admitted to forgetting to lower the grab bar due to the repeated battery issues. Other observations included a resident with an undated, cloudy suction canister and dried tube feeding on the floor, a resident with full and empty urinals on their bedside table, and a resident with mucous secretions on their gown and a saturated tracheostomy dressing. Another resident was found with a yellow stain and brown matter on their bed sheet. Additionally, a resident with a Foley catheter was repeatedly observed without a cover on the catheter bag, despite the expectation that it should be covered. These observations were discussed with the Director of Nursing, who acknowledged the issues.
Failure to Ensure Call Bell Accessibility and Timely Medical Follow-Up
Penalty
Summary
The facility staff failed to ensure that residents on Unit 4 had their call bells readily available, which is crucial for residents to request assistance when needed. During observation rounds, it was noted that one resident's call bell was on the floor, another resident's call bell was initially inaccessible due to limited arm mobility, and a third resident's call bell was found inside a slipper. These observations indicate a lack of consistent verification by staff to ensure call bells are within reach for residents, which is a fundamental aspect of accommodating their needs and preferences. Additionally, the facility did not accommodate a resident's medical needs by failing to schedule a follow-up orthopedic appointment in a timely manner. The resident was admitted with a discharge summary from the hospital that included orders for a follow-up appointment with orthopedic surgery. However, the facility was unable to provide documentation verifying that the appointment was scheduled, transportation was arranged, or that the family was contacted regarding the appointment. This oversight highlights a breakdown in the process of managing and documenting follow-up care for residents after hospital discharge.
Facility Fails to Address Resident Council Concerns
Penalty
Summary
The facility failed to promptly address the recommendations of the resident council concerning issues of resident care and life in the facility. This deficiency was identified through interviews with residents and staff, as well as a review of resident council meeting minutes. During an interview with 10 residents, including members of the resident council, numerous concerns were voiced, many of which were also identified by surveyors. The Life Enrichment Director provided copies of the resident council minutes for November 2024, December 2024, and January 2025, but not for October 2024. The minutes revealed that 20 issues were consistently identified by the resident council over these months, with 18 of the 20 issues in November and all 20 issues in December and January marked as 'Still an issue.' The DON and administrator were informed of these findings during a review of the resident council minutes and an earlier meeting.
Failure to Assess and Assist Residents with Advance Directives
Penalty
Summary
Facility staff failed to assess residents for advance directives and did not offer assistance with creating them. This deficiency was identified for six residents during a survey. Medical record reviews revealed no evidence that these residents or their representatives were assessed for an advance directive, informed of their rights to have one, or provided with written material regarding advance directives. The facility's policy requires that prior to or upon admission, the social director or designee should inquire about the existence of any written advance directives and document any offer to assist the resident in creating one. Despite the policy, the facility did not have documentation showing that the residents or their representatives were offered assistance with creating an advance directive at the time of admission. The Director of Social Services acknowledged the lack of evidence for such offers. The surveyor requested documentation from both the Administrator and the Director of Social Services, but neither could provide evidence that the required inquiries and offers of assistance were made for the residents in question.
Failure to Address Resident Grievances and Missing Property
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without fear of discrimination or reprisal, as evidenced by the case of a resident whose personal property went missing. The resident and their family reported the missing jacket to facility staff, but no follow-up was conducted, and no grievance was filed. The Director of Nursing acknowledged the lack of a grievance record and follow-up, despite the facility's policy that nursing staff or the DON should assist residents in filing grievances and follow up after investigations. Additionally, during a resident council meeting, multiple residents expressed concerns about the grievance process, with many unaware of how to file grievances or where to find information. Some residents feared reprisal if they were to file grievances. The resident council minutes from previous months documented ongoing unresolved issues, and staff interviews confirmed that residents' concerns were not being addressed. The Administrator claimed that grievances were addressed but could not provide documentation, and the Activities Director confirmed the accuracy of the council meeting minutes but could not produce records of resolved grievances.
Deficiencies in Nursing Care and Controlled Substance Management
Penalty
Summary
The facility failed to provide nursing care within professional standards of practice for several residents. Resident #178 was admitted with a requirement for an orthopedic follow-up appointment, which was not scheduled by the facility. Additionally, the resident had a PEG tube in place, but there were no physician's orders for its management, such as flushing or dressing care, during the resident's stay at the facility. Resident #297 had a physician's order for vital signs to be taken on admission and every shift for seven days thereafter. However, the facility did not document complete vital signs for certain shifts, indicating a failure to adhere to the physician's orders. This lack of documentation suggests that the facility did not consistently monitor the resident's vital signs as required. The facility also demonstrated deficiencies in the management of controlled drugs. There were discrepancies in the narcotic counts for several residents, including Resident #150 and Resident #447, where the actual medication count did not match the recorded count on the Controlled Drug Receipt/Record/Disposition forms. Additionally, there were instances where discontinued controlled medications were not destroyed immediately as per facility policy, as observed with Resident #158 and Resident #150. These issues highlight a lack of adherence to protocols for controlled substance management.
Failure to Ensure Timely GNA Certification for CNAs
Penalty
Summary
The facility leadership staff failed to ensure that certified nursing assistants (CNAs) completed a state-approved geriatric nursing assistant (GNA) training program within four months of employment. This deficiency was identified in seven actively employed CNAs. A review of employee records revealed that several CNAs had been working at the facility beyond the four-month timeframe required to obtain their GNA certification. Specifically, CNA #29 had completed their CNA training and received their certificate from the Maryland Board of Nursing, but continued working past the four-month period without obtaining the GNA certification. The facility's administrator was unaware of the four-month requirement, mistakenly believing that CNAs had 12 months to obtain their GNA certification. Additionally, the Human Resources Director confirmed that CNA #77's certification had expired, and they had last worked at the facility on a specific date. The HR Director, scheduling coordinator, and Director of Nursing were responsible for verifying staff licenses and certifications but failed to notice the expiration. This oversight was due to an assumption that CNA #77's certificate was still active, despite receiving monthly emails listing upcoming expiring licenses and certifications.
Failure to Serve Meals According to Menu Tickets
Penalty
Summary
The facility failed to serve meals according to the residents' menu tickets, as observed during a survey. Several residents, including six randomly observed during meals, did not receive the items listed on their meal tickets. For instance, one resident's breakfast tray was missing extra gravy, hot cereal, orange juice, and coffee or hot tea. Another resident's tray lacked hot cereal, orange juice, and coffee or hot tea. Staff interviews revealed that the kitchen ran out of certain items, such as orange juice and coffee, leading to these discrepancies. Additionally, during a lunch tray line observation, it was noted that the facility ran out of several menu items, including Au Gratin Potatoes, apple cake slices, and meatloaf. As a result, residents received substitutions that were not indicated on their meal tickets, such as mashed potatoes instead of Au Gratin Potatoes, baked apple slices instead of apple cake, and baked fish instead of meatloaf. These observations highlight a failure in the facility's ability to provide meals as planned and documented on the residents' menu tickets.
Failure to Maintain Food Temperature
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature, as observed during a survey. On January 15, 2025, the surveyor noted that during the lunch tray line in the kitchen, staff were placing food onto hot plates to maintain an appealing serving temperature. However, the Director of Operations (Staff #58) indicated that they ran out of hot plates, resulting in the last 16 resident plates being placed on trays without a hot plate underneath. These trays were then delivered to the unit without the necessary temperature control. A test tray was requested by the surveyor, and the temperatures of the food items were measured before and after delivery. Initially, the fish entree was at 138.1 degrees Fahrenheit, and the mashed potatoes were at 144 degrees Fahrenheit. After delivery, the temperatures dropped to 124.8 degrees Fahrenheit for the entree and 114.1 degrees Fahrenheit for the mashed potatoes. The surveyors found the food to be unpalatable and not at an appetizing temperature, with the coffee on the tray being room temperature.
Failure to Provide Suitable Bedtime Snacks
Penalty
Summary
The facility staff failed to provide suitable and nourishing alternative meals and snacks to residents who wished to eat at non-traditional times or outside of scheduled meal service times, as per the resident plan of care. This deficiency was identified during a resident council meeting attended by 10 residents, where all attendees expressed dissatisfaction with the availability and delivery of bedtime snacks. The residents reported that snacks were often not delivered to their rooms, were unlabeled, and lacked variety, with only one choice available. Additionally, a resident with special dietary needs stated that these needs were not met by the evening snacks provided. The issue of inadequate bedtime snacks was consistently documented in the resident council minutes for several months, indicating a persistent problem. Interviews with various staff members, including those from different units and the dietary department, confirmed that snacks were sent to the units in bulk and unlabeled. The Senior Director of Operations for food services acknowledged this practice and stated that it was a standard procedure across the facilities he managed, without addressing how personal preferences and dietary considerations were accommodated.
Lack of COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to provide documentation indicating that five Geriatric Nursing Assistants (GNAs) received screening, education, and the offering of the current COVID-19 vaccination. This deficiency was identified during a review of facility records and staff interviews. On January 17, 2025, at 1:17 PM, the records of GNAs #64, #65, #66, #67, and #68 were reviewed, revealing a lack of documentation in their personnel records regarding COVID-19 vaccination procedures. Subsequently, at 1:44 PM, the Infection Preventionist (IP) staff #4 was interviewed and confirmed the absence of documentation for these five GNAs, indicating they had not received the necessary screening, education, and offering of the COVID-19 vaccination.
Failure to Conduct Regular Bedrail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment risks. This deficiency was observed in five residents during the initial phase of the survey. Each of these residents was found in bed with two quarter-length bed rails raised on either side of the top end of their beds. The facility's policy on Bed Safety and Bed Rails required maintenance staff to routinely inspect all beds and related equipment for risks, including potential entrapment hazards. During an interview with the Director of Nursing, it was revealed that the maintenance logs for bedrail entrapment risk were not routinely checked. The Nursing Home Administrator confirmed that maintenance did not regularly inspect bedrails for entrapment risks, although staff assessed all resident bedrails the night before the surveyor's inquiry. This lack of routine inspection and documentation led to the deficiency identified by the surveyors.
Failure to Notify Responsible Parties of Medical Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents regarding significant changes in their medical conditions and care. In the first case, a family member of a resident was not informed about the resident's transfer to the hospital due to chest pain. The family member discovered the transfer incidentally while inquiring about the resident's whereabouts with a nurse. Both responsible parties listed on the resident's face sheet confirmed they were not notified of the transfer, indicating a lapse in communication from the facility. In the second case, a resident's medication was discontinued without notifying the responsible party. The responsible party only became aware of the discontinuation when another family member inquired about the medication with the doctor. The Director of Nursing explained that the nurse or provider is responsible for documenting and notifying the family about medication changes, but this procedure was not followed. The progress notes confirmed the medication discontinuation, yet the family was not informed, highlighting a failure in the facility's notification process.
Verbal Abuse Incident by GNA
Penalty
Summary
The facility failed to prevent verbal abuse of a resident by an employee. During the survey, it was determined that a GNA was overheard by an RN making threatening remarks towards a resident. The incident occurred when the GNA attempted to move the resident, who then became verbally and physically aggressive. The GNA responded by stating that she would harm the resident if not for the resident's mental condition. The GNA admitted in a written statement to making these remarks after being physically assaulted by the resident. The facility's administrator confirmed that the GNA was suspended and subsequently terminated following the investigation. However, the Board of Nursing was not notified of the investigation results, which the administrator acknowledged should have been done.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin in a timely manner to the state agency, which was evident for one resident reviewed for abuse during the survey. The incident involved a resident who reported an injury of unknown origin to an LPN on May 18, 2024, at 4:20 pm. The facility's Self Report Form was submitted to the State Agency on May 19, 2024, without a time indicated by the DON, and the report was received by the State Agency on May 20, 2024, at 12:34 pm. During an interview with the DON and the Administrator, both were unable to explain why the incident was not reported within the required two-hour timeframe.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 145 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 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 | 1.5 mi | ★★★★★ | 10 | 0 |
| Anchorage Rehabilitation And Wellness Center | 1.5 mi | ★★★★★ | 26 | 0 |
| Wicomico Nursing Home | 2.3 mi | ★★★★★ | 13 | 0 |
| Delmar Nursing & Rehabilitation Center | 5.9 mi | ★★★★★ | 6 | 1 |
| Manokin Nursing And Rehab | 13.1 mi | ★★★★★ | 11 | 1 |
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 October 2026) and official state health department websites.