Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bedford Court Healthcare Cent. during CMS and state inspections, most recent first.
Uncovered clean linens were observed in the laundry room, including towels, tablecloths, bed sheets, and clothing stored on tables, racks, and in a basket without covering. The Housekeeping Director stated the laundry room typically had uncovered linen, while the DON said the expectation was for linen to be covered.
The facility failed to consistently document controlled substance counts with the required dual nurse signatures on two nursing units. During medication pass observations, surveyors found multiple missing signatures from incoming and outgoing nurses in the narcotic control records, even though facility practice requires two nurses to jointly count and then sign to verify all controlled medications are accounted for. Nursing staff and the DON confirmed that both outgoing and incoming nurses are expected to sign the narcotic records after each shift-to-shift count.
Improper food storage and labeling were observed in the kitchen. A tray of freshly cooked chicken in the refrigerator was uncovered, a packet of crackers in dry storage was unlabeled, and unlabeled shrimp, cinnamon sticks, and chicken were found in the freezer. The Dining Services Director stated that food items should have been labeled and not left uncovered.
QAPI meetings were not held on a quarterly basis as required, and attendance records showed that required committee members were frequently absent. The QAPI coordinator reported missing binder materials and could not verify a QAPI meeting in one quarter, while review of meeting minutes showed repeated absences by the infection preventionist, Administrator/Board Member, MD, dietitian, and GNA. The coordinator acknowledged that not all required members attended the meetings.
The facility failed to ensure ongoing QAPI training for staff. Review of 5 of 5 employee files found no evidence that an RN, an LPN, and several GNAs received continuing QAPI education after hire. The HR Director could not produce training records, the DON confirmed the staff had not received QAPI training and that no documentation was available, and the NHA acknowledged the lack of records.
A resident was admitted from a hospital with discharge instructions for Eliquis BID, amiodarone QD, and Buspirone BID, but nursing staff used an outdated hospital discharge summary from a prior hospitalization when entering admission orders. As a result, the facility ordered and administered Eliquis QD instead of BID, amiodarone BID instead of QD, initiated Losartan that was not on the current discharge list, and delayed starting Buspirone. The DON later acknowledged that staff misread the date on the discharge summary, and the errors continued for several days until identified by the family.
A resident with dementia, GAD, and MDD was later diagnosed with bipolar disorder, but the record showed no new PASARR screening after the added psychiatric diagnosis. The social service coordinator stated a new PASARR review is usually requested when notified of a new diagnosis, but was unaware of the resident’s bipolar diagnosis and did not submit the referral.
Failure to update care plans for oxygen therapy and a new wound: two residents had care plans that did not reflect current needs. One resident was receiving oxygen therapy, but the care plan had no goals or interventions for oxygen administration, monitoring, or safety precautions. Another resident was re-admitted with respiratory insufficiency requiring 3L O2 and a sacral wound, yet the care plan did not include either condition; the DON stated the admitting nurse was responsible for revising the care plan and that respiratory monitoring should have been added before the end of shift.
The facility failed to maintain professional standards of practice related to oxygen orders and documentation supporting a bipolar diagnosis. A resident was observed receiving oxygen therapy, but the chart did not show an active oxygen order, and the DON stated an order should be present. For another resident with dementia, the record lacked documented behaviors meeting DSM-5 criteria for bipolar disorder; the NP described hallucinations, hyper behavior, exit-seeking, and insomnia, while the physician stated the resident did not have bipolar disorder and the psychiatric notes did not document criteria supporting that diagnosis.
Failure to Maintain Resident Grooming and Personal Care: A resident who needed help with ADLs was observed with greasy hair on multiple occasions and stated not remembering when the hair was last washed. The record showed the resident was scheduled for baths, but only one bath was documented in the EMR, with no evidence of earlier showers or baths or any documented hair washing. Staff said bathing care was documented in the Task Tab, and the DON stated GNAs were expected to document the care provided there.
A resident with a stroke history, hemiparesis, and right-sided contractures had a right-hand splint listed in the care plan, but was observed without the splint and had a contracture of the right hand. Therapy records showed the resident was last evaluated for therapy services in January 2024, with no re-evaluation documented in 2025. The DON confirmed there was only one documented splint refusal and no documented pattern of refusal in the care plan.
The facility failed to obtain physician orders for CPAP treatment for three residents, including one who used the machine nightly. Another resident experienced significant weight loss due to lack of assistance during meals, despite care plan requirements. Additionally, a resident was left unattended after vomiting, as the RN failed to assess or intervene, leaving a gap in care.
The facility failed to secure medication carts, as observed during a survey. Three instances of unattended and unlocked carts containing medications were noted. Staff interviews confirmed awareness of the policy to lock carts when unattended, yet lapses occurred, indicating a systemic issue.
The facility failed to adhere to professional food safety standards, with numerous unlabeled and expired food items found in the kitchens. Staff were unaware of proper labeling practices, and internal temperature monitoring devices were absent, leading to incomplete temperature logs. The Dining Service Director acknowledged these issues, citing staffing problems but admitting there was no excuse for the deficiencies.
The facility failed to properly dispose of waste in the kitchen and dumpster areas, leading to potential contamination and pest attraction. Surveyors observed a pile of empty boxes blocking access to kitchen equipment and an overfilled trash can. In the dumpster area, trash was scattered, and a buildup of dried leaves was noted. The Dining Service Director acknowledged the issues and instructed staff to address them.
The facility did not ensure the presence of required staff members at monthly QA Committee meetings, as revealed by attendance records. Over a six-month period, key personnel such as the DON, IP, and MD were frequently absent, leading to a deficiency noted during a recertification survey.
The facility failed to provide access to grievance forms as required by its policy. A complaint was filed after a resident and a complainant were denied copies of grievance forms by the Social Service Director, who cited the facility's policy of keeping such documents internal. However, the facility's grievance policy stated that these forms should be accessible to residents, family, and team members. The Nursing Home Administrator confirmed the policy's requirements and the discrepancy in its implementation.
A resident did not receive scheduled showers as part of their ADL care, as confirmed by a formal complaint and medical record review. The resident was supposed to have showers on specific days, but only received a bed bath twice and a shower once over several weeks. The NHA acknowledged the error, noting that the bathing order was mistakenly marked as 'as needed.'
A resident was repeatedly observed slumped over asleep in a wheelchair at the dining table, with drool on their lap and no assistance from staff. Despite having a plate of food in front of them, the resident did not eat, and staff intervention was required to awaken them. The ADON acknowledged the situation as unacceptable.
The facility did not post the location of the most recent state survey results and plan of correction in an accessible area for residents, family members, and visitors. This was observed during a recertification survey and confirmed by the Nursing Home Administrator, who acknowledged the oversight.
The facility failed to document that advance directives were offered to two residents, despite their capacity to make such decisions. The Social Worker confirmed that while she routinely offered advance directives, she did not document these interactions in the medical records, leading to a deficiency noted during a recertification survey.
A facility failed to develop a comprehensive care plan for a resident's splint use, despite physician orders for a left upper extremity rigidity splint and a soft brace elbow. The resident, observed with left arm weakness, had no care plan formulated since the orders were issued. Interviews confirmed the absence of a care plan, highlighting a deficiency in care planning processes.
A resident's care plan was not updated after the completion of IV antibiotic treatment and removal of a PICC line. Despite the PICC line being removed, the care plan continued to include interventions for PICC line care, which were no longer necessary. This oversight was confirmed through interviews and medical record reviews, highlighting a failure to revise the care plan to reflect the resident's current needs.
The facility failed to maintain oxygen therapy equipment according to professional standards for two residents, as their oxygen tubing and humidification bottles were not labeled. Observations and interviews revealed that the equipment was not labeled as required by physician orders, and staff were unaware of when the equipment was last changed. The ADON confirmed the expectation for staff to change and label the equipment weekly.
The facility failed to maintain accurate medical records for two residents, leading to medication administration errors and inadequate monitoring. One resident received Ibuprofen for pain instead of fever, while another's medication orders for monitoring were not transmitted to the TAR, resulting in a lack of side effect monitoring. Additionally, a wound care plan was not documented in the TAR, indicating lapses in record-keeping.
The facility was found deficient in maintaining a sanitary environment and ensuring functional equipment. The laundry room had dirty floors and damaged walls, while a resident's room had a broken toilet paper holder. The NHA acknowledged the issues and entered a work order for the broken holder after it was pointed out.
Uncovered Clean Linens Stored in Laundry Room
Penalty
Summary
The facility failed to store and process linens to prevent the spread of infection, as shown by one observation in the laundry room. On 03/19/2026 at 8:47 AM, surveyors observed clean laundry stored uncovered, including towels on a rectangular table, clean tablecloths on a metal rack, another metal rack containing tablecloths, bed sheets, towels, and clothing, and clean linens in a basket, all left uncovered. During an interview at that time, the Housekeeping Director stated that the laundry room typically had uncovered linen. Later that morning, the Director of Nursing stated that the expectation was for linen to be covered.
Failure to Consistently Document Dual Nurse Signatures for Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to consistently document controlled substance counts with the required dual nurse signatures during shift-to-shift narcotic counts on two of three units. On the Choice unit, during a medication pass observation with an LPN, review of the narcotic control book showed a missing incoming nurse signature for the 3:00 PM to 11:00 PM shift and a missing outgoing nurse signature for the 11:00 PM to 7:00 AM shift on a specific date. The assisting nurse from another unit who helped complete the narcotic count during a family emergency for the scheduled incoming nurse did not sign the narcotic book, despite the expectation that both outgoing and incoming nurses sign after jointly counting narcotics. On the Independence unit, during another medication pass observation with an LPN, review of the narcotic binder revealed three missing signatures: an incoming nurse signature for the 3:00 PM to 11:00 PM shift, an outgoing nurse signature for the 11:00 PM to 7:00 AM shift on the same date, and an incoming nurse signature for the 11:00 PM to 7:00 AM shift on a different date. The LPN on that unit confirmed the missing signatures and stated that both outgoing and incoming nurses are required to sign to verify that narcotics were counted. The DON also confirmed that facility expectations require two nurse signatures after a joint count to document that all controlled medications are accounted for, and acknowledged the missing signatures when informed of the findings.
Improper Food Storage and Labeling in Kitchen Areas
Penalty
Summary
Food items were not stored in a manner that maintained their integrity in the kitchen areas. During an initial observation on 03/16/2026, a tray of freshly cooked chicken in the refrigerator was found uncovered, a packet of crackers in dry storage was found unlabeled, and unlabeled shrimp, cinnamon sticks, and chicken were observed in the freezer. During an interview on 03/17/2026, the Dining Services Director stated that food items should have been labeled and not left uncovered.
QAPI Committee Failed to Meet Quarterly and Lacked Required Members
Penalty
Summary
The facility failed to conduct QAPI meetings on a quarterly basis and failed to ensure that required QAPI committee members were present at the meetings. During the survey, the QAPI coordinator reported that the facility’s QAPI binder was missing and that attendance sheets for April 2025, May 2025, and October 2025 could not be found. She initially stated that quarterly QAPI meetings were held in April 2025, July 2025, October 2025, and January 2026, but later confirmed there was no evidence that a QAPI meeting was held in April 2025. Review of the attendance sheets and meeting minutes for the prior 12 months showed repeated absences of required members. The infection preventionist was absent for 7 months, the Administrator or Board Member was absent for 2 months, the Medical Director was absent for 2 months, the Dietitian was absent for 8 months, and the GNA was absent for 7 months. The QAPI coordinator acknowledged that not all members of the quality assurance committee attended as required and stated the facility had been encouraging staff participation to meet federal and state attendance requirements.
Lack of Documented QAPI Training for Staff
Penalty
Summary
The facility failed to ensure staff received ongoing QAPI training. During review of 5 of 5 employee files, no evidence was found that RN #16, LPN #17, and GNAs #18, #19, and #20 had received continuing QAPI education after their initial hire. The GNAs reviewed had hire dates ranging from 2003 through 2025, showing employment without documented continuation of QAPI training. During interviews, the HR Director stated she was responsible for ensuring staff maintained required training and said she would locate documentation of QAPI training for the identified employees, but she was unable to produce any records. The DON later confirmed that the identified staff members had not received QAPI training and that no documentation was available to support that the training had been conducted. The NHA stated that staff are expected to receive QAPI training but did not have access to training records, and acknowledged the concern when informed of the lack of documentation.
Failure to Verify Hospital Discharge Orders Resulting in Medication Errors
Penalty
Summary
The facility failed to ensure that a newly admitted resident was free from significant medication errors by not verifying the accuracy of hospital discharge paperwork before entering admission medication orders. The resident was admitted from the hospital with discharge paperwork dated 02/20/2026 that listed Eliquis 5 mg by mouth twice daily, amiodarone 200 mg by mouth once daily, and Buspirone 5 mg by mouth twice daily. Facility records showed that orders were instead entered for Eliquis 5 mg by mouth once daily and amiodarone 200 mg by mouth twice daily, both starting on 02/21/2026 and discontinued on 02/25/2026, and these medications were administered as ordered. Additionally, Losartan Potassium 50 mg by mouth once daily was ordered and administered from 02/21/2026 through 02/27/2026, even though this medication was not listed on the hospital discharge medication list. Buspirone was not started until 02/27/2026, despite being included on the hospital discharge medication list. During interviews, the Medical Director confirmed that a medication error had occurred involving these medications for the resident and stated that the errors were present when he evaluated the resident. The DON reported that the facility had received a hospital discharge summary from a prior hospitalization dated 07/18/2025 and that nursing staff misread the date and did not identify that it was from an earlier admission. As a result, the resident received incorrect medications for the first four days of their stay until the error was identified by a family member. The surveyor reviewed the 07/18/2025 hospital discharge paperwork and confirmed that the wrong discharge summary had been used, leading to the inaccurate medication orders and administration.
Failure to Refer for PASARR Review After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a PASARR evaluation review after a new mental health diagnosis was added. Resident #4 was admitted with diagnoses including dementia, generalized anxiety disorder, and major depressive disorder, and an admission PASARR Level I screen dated 7/14/21 documented no mental health, intellectual disability, or related conditions. The resident was later diagnosed with bipolar disorder on 1/9/26, but there was no evidence in the medical record that a new PASARR screening was completed after this diagnosis was added. During interview, the social service coordinator stated that when notified of a new diagnosis or medication, a new PASARR review is re-applied for, but said they were not aware of Resident #4's bipolar diagnosis and therefore did not submit the resident for a new PASARR evaluation.
Failure to Update Care Plans for Oxygen Therapy and New Wound
Penalty
Summary
The facility failed to develop and/or update the comprehensive care plan for 2 residents reviewed during the recertification survey. Resident #1 was observed receiving oxygen therapy, and record review showed the resident’s MDS indicated oxygen therapy was in use; however, the comprehensive care plan contained no goals or interventions addressing oxygen therapy, including administration, monitoring, or safety precautions. The DON stated that residents receiving oxygen therapy were expected to have this addressed in the comprehensive care plan. Resident #49 was re-admitted to the facility with a new diagnosis of respiratory insufficiency requiring 3L of oxygen, and records also showed the resident returned with a wound to the sacrum and had a new order for oxygen at 3L via nasal cannula continuously every shift. Review of the care plan showed it did not include the new sacral wound or supplemental oxygen therapy. The DON stated that the admitting nurse was responsible for revising the care plan after admission or re-admission, and that if revisions were not done, the nurse supervisor could update it; the DON also stated that respiratory monitoring should have been added to the care plan before the end of shift.
Missing Oxygen Order and Unsupported Bipolar Diagnosis
Penalty
Summary
The facility failed to maintain professional standards of practice related to oxygen orders for Resident #1. During an observation, Resident #1 was seen receiving oxygen therapy, but a subsequent record review did not reveal an active order for oxygen. The Director of Nursing stated that if a resident is on oxygen, there should be an order to reflect it. The facility also failed to provide sufficient documentation to support a new diagnosis of bipolar disorder for Resident #4. The resident had a prior diagnosis of moderate dementia with other behavioral disturbances, and later was diagnosed with bipolar disorder, unspecified. Review of the MDS and medical record did not show documented evidence of bipolar behaviors in the relevant assessment sections or in the chart between the MDS assessment and the bipolar diagnosis. The NP stated the resident had hallucinations, hyper behavior, exit-seeking, and insomnia, while the physician stated the resident did not have bipolar disorder and did not meet the criteria for that diagnosis. Caregiver interviews described the resident as unable to hold a conversation and noted lethargy and decreased interaction, and the psychiatric provider's notes did not document bipolar disorder or behaviors meeting diagnostic criteria.
Failure to Maintain Resident Grooming and Personal Care
Penalty
Summary
The facility failed to maintain good grooming and personal care services for one resident who was unable to perform activities of daily living independently. Resident #6 was observed on 3/16/26 with greasy hair and stated that the resident only remembered getting showered one time when the hair was washed. On 3/19/26, the resident was again observed in bed wearing a hospital gown with hair that appeared greasy, and the resident stated being unsure when the hair was last washed. Record review showed the resident was admitted on [DATE] and was scheduled for baths on Wednesdays and Saturdays. The GNA task documentation showed a bath was provided on 3/18/26 at 10:27 PM with partial/moderate assistance, but there was no documentation of any showers or baths before that in the EMR. During interview, the resident stated a preference for bed baths and said a bed bath was given the prior night, but the resident did not remember the last time the hair had been washed. Staff stated that showers and baths were documented in the Task Tab of the medical record system, and the DON stated the expectation was that the GNA would document the care given in that tab.
Failure to Maintain ROM and Re-evaluate Therapy Needs
Penalty
Summary
The facility failed to provide appropriate treatment to maintain a resident’s limited ROM and failed to evaluate the resident for therapy services to prevent further decline in ROM. Resident #19 reported having had a stroke during the stay at the facility and stated that a splint had been used on the right hand but was taken away by therapy services. During observation, the resident had a contracture of the right hand and was not wearing a right-hand splint when later observed. The care plan identified musculoskeletal condition, hemiparesis, and contracture of the right upper and lower extremity, and included an intervention for the resident to wear a right elbow and right-hand splint per doctor’s order. Record review showed the resident was last evaluated for therapy services in January 2024, and facility therapy notes included a statement that the resident had refused to wear a splint. The Director of Therapy Services stated the facility’s expectation was that residents be evaluated quarterly and confirmed there were no records showing the resident was re-evaluated for therapy services in 2025. The DON stated that if a resident refused an intervention, staff were expected to educate the resident and try again later, and that a pattern of refusals should be documented, the provider and resident representative notified, and the care plan updated; however, she confirmed there was no documented pattern of splint refusals beyond a single note in January 2024 and the care plan had not been updated to reflect a pattern of refusal.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to obtain physician orders for CPAP treatment for three residents, including Resident #17. During a survey, it was observed that Resident #17 had a CPAP machine on their bedside table and used it nightly for sleep issues. However, a review of the resident's clinical record revealed no physician's order for the CPAP treatment until the surveyor's inquiry prompted the Director of Nursing to obtain one. This oversight indicates a lapse in ensuring that all medical treatments are properly documented and authorized by a physician. Resident #8 was observed multiple times in a state of neglect, slumped over in a wheelchair or bed, with food trays untouched and no staff assistance provided. The resident experienced significant weight loss, and their care plan indicated a need for supervision or assistance while eating. Despite this, the resident was left unattended during meals, leading to further weight loss and signs of malnutrition. Additionally, the resident's care plan required the use of an abduction pillow post-surgery, but observations showed the pillow was not consistently in place, and staff falsely documented its use. Resident #292 experienced vomiting and pain, but the RN on duty failed to assess or intervene, leaving the resident unattended. The RN left the facility before being relieved by the incoming nurse, resulting in a gap in care. The resident's daughter reported that no nurse attended to her mother for about an hour after the vomiting incident. This lack of timely response and communication among staff members highlights a deficiency in maintaining quality care and ensuring residents' immediate needs are addressed.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to maintain a secure system for medication storage, as evidenced by three separate observations of unattended and unlocked medication carts during a re-certification survey. On the first occasion, a medication cart was found unlocked and unattended, with drawers containing both prescribed and over-the-counter medications accessible. Additionally, a laptop displaying resident names was left open. This incident occurred when an RN left the cart to attend to a resident, acknowledging the oversight and citing a rough night as the reason for the lapse. Subsequent observations revealed similar deficiencies, with two more instances of unlocked and unattended medication carts. In both cases, the carts contained medications labeled with resident names and room numbers. The facility's policy requires that medication carts be locked when unattended, a policy that was not adhered to by the staff involved. Interviews with the staff confirmed awareness of the policy, yet the lapses continued, indicating a systemic issue in securing medication carts as per the facility's guidelines.
Food Safety and Labeling Deficiencies
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards of food service safety, as observed during a survey. In the Dining Room Kitchen, several food items were found improperly labeled or not labeled at all, including cooked ham, cheese, Rice Krispies, and peanut butter. The Lead Dietary Aide admitted to not knowing the correct expiration dates for these items and acknowledged the presence of expired Old Bay seasoning. This lack of proper labeling and disposal of expired items was confirmed during interviews with facility staff. In the Main Kitchen, numerous food items were found opened without labels or expiration dates, including roasted peppers, muffins, cookie dough, tomato sauce, and various dressings. Additionally, expired items such as bananas and lingonberries were discovered. The Lead Cook confirmed these items were expired and should have been disposed of. The surveyors also noted a sign instructing staff to label all open items, which was not being followed. Furthermore, the facility lacked internal temperature monitoring devices in refrigerators and freezers, and temperature logs were incomplete. The Lead Cook was unaware of the need for internal temperature devices, relying instead on external thermometers. The Dining Service Director acknowledged the issues with labeling, expired items, and temperature monitoring, attributing some of the problems to staffing issues but recognizing there was no excuse for the deficiencies.
Improper Waste Disposal in Kitchen and Dumpster Areas
Penalty
Summary
The facility failed to properly dispose of waste in the kitchen area, leading to potential contamination and pest attraction. During an initial tour of the main kitchen, surveyors observed a pile of 14 empty boxes blocking the doors of the refrigerator, freezer, and holding warmer. Additionally, a trash can beside the door was overfilled, preventing the lid from closing completely, with several cans visible on top of the trash. Interviews with the lead staff and the Dining Service Director confirmed that the trash should not have been there and acknowledged the issue without providing an excuse. Further observations in the dumpster area revealed improper waste disposal, with trash scattered over several areas, including disposable cups, papers, and carry-out trays. There was also a heavy buildup of dried leaves around the dumpster area. A cart with two bags of trash and a stack of boxes were noted beside the dumpster, waiting to be thrown out. The Dining Service Director acknowledged the situation and instructed a dietary employee to ensure the trash is disposed of properly to prevent rodent attraction.
QA Committee Meetings Lacked Required Staff Attendance
Penalty
Summary
The facility failed to ensure the required staff members were present for each of the monthly Quality Assurance (QA) Committee meetings, as revealed during a review of the Quality Assurance and Performance Improvement (QAPI) program during the recertification survey. Specifically, attendance sheets for the past six months showed that in May, the Director of Nursing (DON), Infection Preventionist (IP), and Medical Director (MD) were absent. In June, the DON and IP were not present, and in July, the DON, IP, and MD were again absent. This deficiency was identified during an interview with the Nursing Home Administrator (NHA) and a subsequent review of the attendance records.
Failure to Provide Access to Grievance Forms
Penalty
Summary
The facility failed to ensure that grievance forms were accessible to residents, family, and team members, as required by their own grievance policy. This deficiency was identified during a review of a formal complaint filed with the Office of Healthcare Quality. The complaint involved verbal grievances filed by the Social Service Director on behalf of a resident and a complainant. The complainant requested copies of the written grievances, but the request was denied based on the facility's policy, which considered grievance forms as internal documents not for public view. Upon reviewing the facility's grievance policy, it was found that the policy explicitly stated that grievance reports should be readily accessible to residents, family, and team members. However, the Social Service Director's actions were contrary to this policy, as she denied the complainant's request for access to the grievance forms. The Nursing Home Administrator confirmed the policy's requirements and acknowledged the discrepancy between the policy and the actions taken by the Social Service Director.
Failure to Provide Scheduled ADL Care for a Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for Resident #244, as evidenced by the lack of scheduled showers. A formal complaint was filed with the Office of Healthcare Quality, indicating that the resident did not receive showers as scheduled during their stay. A review of the resident's medical records confirmed that showers were scheduled for Tuesday and Friday evenings. However, the records showed that the resident only received a bed bath on two occasions and a shower on one occasion over a period of several weeks. During an interview, the Nursing Home Administrator (NHA) acknowledged that the resident did not receive the scheduled bed baths and showers due to an error in the bathing order, which was incorrectly marked as 'as needed.'
Failure to Respect Resident's Dignity
Penalty
Summary
The facility failed to respect a resident's dignity, as observed in the case of Resident #8. During multiple observations, the resident was found slumped forward asleep in a wheelchair at the dining room table, with drool draining from their mouth onto their lap. On one occasion, a plate of food was placed in front of the resident, but no food had been eaten, and no assistance was provided by the staff. Attempts by a Geriatric Nursing Assistant to awaken the resident required loud calling and physical shaking, after which the resident appeared groggy and unable to hold their head up. On a subsequent day, the resident was again observed slumped over asleep in their wheelchair at lunch, with wet spots on their shirt from drool, and no food had been delivered. Despite the presence of a plate of food later, the resident remained asleep and unattended. The Assistant Director of Nursing was informed of the situation and upon returning to the dining room, found the resident still asleep with untouched food. The ADON had to wake the resident by calling their name loudly and shaking their shoulders, noting the situation as unacceptable.
Failure to Post Survey Results Location
Penalty
Summary
The facility failed to ensure that the location of the most recent state survey results and plan of correction were posted in a place readily accessible to residents, family members, and visitors. During the recertification survey, observations made by the surveyor on two separate occasions did not reveal any posted notification indicating where these documents were located. This deficiency was confirmed in an interview with the Nursing Home Administrator, who acknowledged the oversight and stated an intention to address the issue immediately.
Failure to Document Offer of Advance Directives
Penalty
Summary
The facility failed to provide evidence that advance directives were offered to two residents during a recertification survey. Specifically, for two of the four residents reviewed, there was no documentation in their medical records indicating that they were offered the opportunity to formulate an advance directive. Both residents were determined to have the capacity to make such decisions, as indicated by completed capacity forms. However, the facility's records lacked any evidence of discussions or offers regarding advance directives prior to the surveyors' intervention. During an interview, the Social Worker confirmed that while she routinely checked for advance directives and offered residents the opportunity to formulate one, she did not document these interactions in the medical records. This lack of documentation was evident in the cases of the two residents reviewed, as their records did not reflect any offer or discussion of advance directives until after the surveyors intervened. The deficiency was brought to the facility's attention during the exit meeting of the survey.
Failure to Develop Comprehensive Care Plan for Splint Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for the use of a splint for Resident #37. This deficiency was identified during a recertification survey, where it was observed that the resident, who had left arm weakness, was using a half lap board arm rest attached to the wheelchair, and a plastic splint was noted on the windowsill. Despite physician orders dated 11/18/2024 for the use of a left upper extremity rigidity splint during the day shift and a soft brace elbow at bedtime, there was no evidence of a care plan for the splint use in the resident's medical record. Interviews with the Nursing Home Administrator and the acting Director of Nursing confirmed the absence of a care plan for the splint. The acting DON explained the process for formulating care plans, which involves the nurse completing the admission assessment and updating the care plan with input from the DON, NHA, Social Worker, and Resident Assessment Coordinator when changes are needed. However, despite being notified of the splint order on 11/18/2024, the care plan was never formulated, leading to the deficiency.
Failure to Update Care Plan After PICC Line Removal
Penalty
Summary
The facility staff failed to review and revise the interdisciplinary care plans to accurately reflect the current needs of the residents. This deficiency was identified during a survey process, specifically for one resident who was admitted with physician orders for intravenous antibiotic treatment via a peripherally inserted central catheter (PICC) line for Osteomyelitis. The resident's antibiotic treatment ended, and the PICC line was removed, but the care plan continued to include interventions related to the PICC line, which were no longer applicable. The deficiency was confirmed through interviews and medical record reviews. The resident informed the surveyor that the antibiotic treatment had ended, and the PICC line was removed approximately two weeks prior. However, the care plan still included interventions for PICC line care, such as changing the site dressing and flushing the line, even after its removal. The Director of Nursing confirmed that these interventions should have been discontinued once the PICC line was removed, indicating a failure to update the care plan in a timely manner.
Failure to Label Oxygen Therapy Equipment
Penalty
Summary
The facility failed to maintain oxygen therapy equipment according to professional standards of practice for two residents during the annual survey. Observations revealed that the oxygen tubing and humidification bottles for both residents were not labeled, which is contrary to the physician's orders. Resident #24's oxygen equipment was observed without labels on two separate occasions, and the Licensed Practical Nurse (LPN) confirmed the lack of labeling and was unaware of when the equipment was last changed. Similarly, Resident #11's oxygen equipment was also found unlabeled during observations, and the LPN again confirmed the absence of labeling and the uncertainty regarding the last change. Interviews with the LPN and the Assistant Director of Nursing (ADON) highlighted that the facility's protocol requires oxygen tubing and humidification bottles to be changed weekly and labeled accordingly. However, the LPN admitted to assuming the equipment was changed based on the date written on the humidification bottle, which was not present. The ADON reiterated the expectation for staff to follow physician orders and label the equipment. The Nursing Home Administrator and Regional Director of Clinical Care were informed of these concerns during the survey.
Deficiencies in Medication Administration and Record-Keeping
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in medication administration and monitoring. For one resident, Ibuprofen was administered for pain instead of fever, despite the absence of any recorded fever episodes. The Licensed Practical Nurse (LPN) was aware of the resident's pain but did not follow the correct medication order, which was later clarified by the Director of Nursing (DON) to be for breakthrough pain. This discrepancy in medication administration was not documented properly in the resident's medical records. Another resident's medical records revealed that physician's orders for monitoring various medications, including an antipsychotic, antidepressant, anticoagulant, and behavior monitoring, were not transmitted to the Treatment Administration Record (TAR). This oversight resulted in the resident not being monitored for potential side effects of these medications. Additionally, there was a discrepancy in the indication for Mirtazapine, which was incorrectly documented as being for bipolar disorder instead of an appetite stimulant. The Assistant Director of Nursing (ADON) confirmed these errors and acknowledged the failure to monitor the resident's medication side effects. Furthermore, the resident's wound care plan, which included the use of pressure-relieving boots for a deep tissue injury, was not documented in the TAR. The ADON confirmed that the order for the boots was not listed, indicating a lapse in ensuring that the resident's care plan was accurately reflected in their medical records. These deficiencies highlight significant gaps in the facility's documentation and medication management processes.
Sanitation and Equipment Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a sanitary environment and ensure functional equipment, as observed during a recertification survey. In the laundry room, the floor tiles were visibly dirty with dark residue and dirt accumulation between washing machines. The wall below the shelf housing washing machine chemicals was peeled and damaged, and a brown substance was noted on the wall above the eye wash station. These findings were confirmed by Staff #15 and the Housekeeping Supervisor, Staff #16, who attributed the wall damage to leakage from the chemical unit. Additionally, in one resident room, the toilet paper holder wall mount was broken, with one arm mount missing and the roll holder absent. The Nursing Home Administrator (NHA) was shown the broken dispenser and acknowledged that it had not been reported in their electronic maintenance system, TELS. The NHA later entered the work order request into the system, confirming the deficiency in addressing maintenance concerns promptly.
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 1,508 citations issued within 25 miles in the last 12 months — including the 13 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Silver Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Layhill Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 42 | 0 |
| Complete Care At Wheaton | 3.2 mi | ★★★★★ | 0 | 0 |
| Friends Nursing Home | 3.5 mi | ★★★★★ | 1 | 0 |
| Montcare At Wheaton | 3.9 mi | ★★★★★ | 0 | 0 |
| Brooke Grove Rehab. & Nsg Ctr | 4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.