Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 Complete Care At Hagerstown during CMS and state inspections, most recent first.
A resident with no decision-making capacity had an advance directive naming a medical and financial POA, but staff could not locate it in the EMR despite stating it should be in the Miscellaneous section. The record also showed conflicting code status documentation, including a No CPR discharge order, DNR/DNI orders, and later a Full Code MOLST, with no evidence the advance directive had been uploaded or maintained in the chart.
A cognitively intact resident with medication administration concerns filed a grievance after reporting a thyroid medication error and repeated near-misses with incorrect doses. The facility documented the complaint and noted that nursing education was provided and the medication order was updated, but it did not give the resident a written grievance decision with the required investigation findings, confirmation status, or outcome details. The NHA confirmed the facility was only giving grievance outcomes verbally.
Incomplete investigations of neglect allegations: The facility concluded two neglect allegations were unsubstantiated even though resident interview and observation forms were left blank in the investigation files. In one case, a CNA was alleged to have told a resident to go in a brief instead of assisting with toileting; in the other, a resident’s sister alleged neglect involving oral hygiene, hair hygiene, incontinence care, nutrition, and staffing. The ADON acknowledged the records did not show that the investigations were completed thoroughly before the conclusions were made.
A resident’s MDS was coded inaccurately for both an antipsychotic and a scheduled pain medication. The MAR showed the resident received Risperdal for delusional disorder and tramadol for pain as ordered, but the MDS incorrectly indicated no antipsychotic was received and no scheduled pain regimen was received, which also caused the GDR questions to be skipped. The MDS nurse later acknowledged the items were coded in error.
A resident with documented hearing aid use and intact cognition had no care plan addressing hearing aid needs. The MDS and an order showed hearing aids were present and to be placed and removed by nursing staff, but the resident later reported one hearing aid had been lost and the UM stated both hearing aids were gone. Review of the care plan found no documentation for hearing aid use.
A resident’s care plan meetings were not held after completed MDS assessments, despite notes showing meetings were scheduled and then rescheduled at the resident’s request and due to a doctor’s appointment. The record showed no care plan meeting had occurred since December, and the SSD confirmed this when questioned by the surveyor. The DON was informed that no interdisciplinary care conference had been held following the MDS assessments for more than 6 months.
Inaccurate Documentation of Hearing Aid Care: Staff failed to accurately document a resident’s hearing aid care despite an order to place the aids in the resident’s ears each morning and store them in the med cart each evening. The resident, who was cognitively intact, reported the hearing aid was missing after it had been placed in a cup on the med cart, and the MAR still showed repeated entries indicating the aids were provided and secured even after they were gone.
Failure to provide timely ADL and incontinence care was identified for a resident with a hx of stroke, urinary incontinence, IBS, and other conditions requiring assistance. The resident reported using the call bell for help during the overnight shift but said no one returned, and staff statements conflicted about whether the call was answered. Review of task documentation showed limited care just after midnight, no bladder documentation overnight, and no further incontinence-related care until nearly 1:00 PM, while the DON confirmed the resident was not changed, turned, or dried after midnight until the next shift.
Failure to Provide Planned Activities: Two residents with dementia and significant cognitive impairment did not receive activities documented in their care plans. One resident with a hx of stroke and dependence for mobility had a stated preference for blues and jazz music, but records showed TV documented as the activity and no evidence that music was offered. Another resident with severe cognitive deficits had care plan preferences for music and church services, yet records showed TV documented as the activity and no documentation that music or religious services were offered.
A facility failed to rotate insulin injection sites for residents receiving multiple daily insulin injections, with records showing repeated use of the same arm and abdominal sites over several days. A resident with diabetes and severe cognitive impairment and another resident with MS and intact cognition both had insulin administered in the same locations repeatedly, and one resident and spouse reported concerns about how injections were given. The facility also failed to ensure a GNA reported a resident’s bleeding toes after a shower to nursing staff when the GNA observed the injury during care.
A cognitively intact resident with a documented hearing aid had no care plan documentation for hearing aid use, and staff records became incomplete after the hearing aid was reportedly placed in a cup on the med cart and then went missing. Interviews showed staff could not confirm the device was secured, the audiology provider had not been notified of the loss, and there was no clear running list or documented communication process for the missing hearing aid.
A dependent resident with MS who required a mechanical lift and two staff for transfers was struck above the eye by a Hoyer lift when a GNA brought the equipment into the room and the lift swung forward during the transfer process. The resident and spouse reported the aide was rushing and rough, and facility interviews confirmed the aide later acknowledged the lift bumped the resident while she was not being careful.
Two residents receiving hemodialysis were given scheduled morning medications before dialysis without a physician or nephrology order authorizing the practice. MARs showed the meds were administered immediately before treatment on multiple occasions, but the hemodialysis communication records were incomplete and did not document medication communication to the dialysis provider. Staff and the DON acknowledged there was no written order directing the practice, and the care plans did not include a physician-directed intervention for pre-dialysis medication administration.
The facility failed to ensure monthly pharmacist MRR recommendations were consistently reviewed and addressed by providers. For one resident on Quetiapine, the pharmacist recommended a GDR, but the initial recommendation was not documented as addressed by the PCP, and the later referral to psych was not shown to have been reviewed before the dose change. For another resident, the pharmacist recommended discontinuing Melatonin, but the NP only referred the issue to psych, and the psych NP stated she never reviewed or addressed the recommendation in her notes.
A resident received PRN oxycodone on multiple occasions even though the documented pain scores were below the ordered threshold, and the record did not consistently show non-pharmacological interventions before administration. Another resident had insulin lispro given at meal times despite BS readings below the hold parameter of 100. The MAR and progress notes did not support that the medications were administered in accordance with the ordered parameters.
A resident with hyperkalemia had abnormal lab results available at the facility, but they were not uploaded into the EMR in time for provider review. An on-call NP relied on an older normal potassium result and gave an order to hold a potassium-lowering med, while another NP later documented elevated potassium and ordered continued treatment. Staff could not locate the more recent lab reports in the chart, and the DON confirmed the facility’s lab retrieval and scanning process left the results out of the resident’s record.
Failure to Follow Up on Dental Referral: A resident with respiratory failure and DM was seen by dental and told that retained roots needed surgical extraction, but the oral surgery referral was not scheduled. The ADON said the follow-up process depended on unit manager communication to the scheduler, and she was unaware the resident needed an oral surgeon appointment until the survey team identified the missed follow-up.
Failure to have a qualified food service director was identified when the Dietary Manager stated he was not a CDM, the RD confirmed she only coordinated diet-related issues and had no kitchen oversight, and the CDM certificate belonged to a corporate employee who was only at the facility 1-2 days per week. The NHA believed the arrangement was acceptable because the facility had a full-time RD, but no documentation showed the RD had full-time managerial duties or that the Dietary Manager met state requirements.
Menus were not followed for a pureed meal service. A cook identified pureed tray items as mashed potatoes, spinach, and turkey, but the posted dinner menu listed winter blend vegetables and baked macaroni and cheese. The Corporate Chef confirmed spinach was used as the pureed vegetable and that mashed potatoes were being served instead of mac and cheese for consistency. A resident with a pureed diet order had family report concern that the resident did not get the same food as others and sometimes received an all-white tray.
Food service sanitation and storage were not maintained as required. Surveyors observed a heavily cut and stained cutting board along the tray line, cups stored open side down while still wet, an ice machine in a nourishment room with reddish buildup and black splotches, and unlabeled, undated food containers in a refrigerator. The DM and Corporate Chef acknowledged the observations, and staff gave conflicting information about who cleaned the unit ice machine.
A resident’s EMR contained conflicting MOLSTs and code status orders, with the prior MOLST not voided or retained in the active or archived record as required. In another case, a resident’s fall-related change in condition form was struck out as incomplete even though staff could not explain why, and the hospital transfer form contained inconsistent timing and vital signs that appeared to pull data from the next day instead of the event day.
Staff failed to maintain a homelike environment when a water-stained ceiling tile and damaged drywall behind a bed in two resident rooms were not identified or reported. While the Maintenance Director stated that weekly and monthly audits are conducted and that staff are expected to submit work orders through TELS, no work orders were received for these issues. The DON did not believe any work orders had been submitted, a GNA reported not noticing the damaged drywall, and an RN acknowledged not paying attention to maintenance concerns during rounds, allowing the environmental damage to remain unaddressed in the residents’ rooms.
Facility staff failed to clarify and correctly implement a verbal IV fluid order for a resident receiving Lactated Ringers for dehydration. The EHR showed an order for IV fluids at a specified rate for 2 days, with documentation of administration on two days but no record of fluids being given on the subsequent day. The DON later explained that the intended regimen was multiple liters over 2 days, but described the order as poorly written and confusing, and acknowledged it was not clarified. An NP note documented IV fluids to continue for 48 hours, but the NP later stated this was a typo and that a new order was written in error when a new IV bag was started, contributing to the resident not receiving the full intended course of IV fluids.
A resident admitted with talar osteomyelitis of the left foot had additional wounds documented by the admitting nurse, including a scab on the left ankle, a sore on the left foot, and a sore on the left heel, but no wound treatment orders were obtained at admission. The attending physician repeated the hospital osteomyelitis note, documented no skin lesions, did not address the additional wounds, and did not initiate wound care, stating later that a wound specialist handles such care. The wound NP did not assess the resident until 10 days after admission, at which time a venous ulcer on the left medial malleolus, a left plantar diabetic foot ulcer, and an unstageable pressure ulcer on the left heel were identified and treatment started. The DON reported that the admitting LPN should have clarified the discharge instructions and notified the physician for orders for all identified wounds.
A cognitively impaired resident with a history of hemorrhagic stroke was incorrectly assessed on admission as unable to ambulate, which locked the elopement assessment and led to the resident being classified as not at risk for elopement despite prior functional independence and hospital therapy notes showing ambulation with a walker. After admission, the resident experienced falls while trying to walk, was documented as severely cognitively impaired and incapable of making decisions, and demonstrated improved mobility, poor safety awareness, wandering, and frequent statements about wanting to go home, but the facility did not reassess elopement risk or implement elopement precautions. On the day of the incident, the resident walked down the hall carrying personal items, exited the front door unchallenged while assigned staff were passing dinner trays, and was later found by a visitor lying on the ground in the parking lot in dark, cold conditions, having fallen and sustained abrasions and scrapes, while staff and leadership acknowledged that the resident had not been identified or monitored as an elopement risk.
Facility staff did not conduct required annual performance evaluations for multiple GNAs, preventing systematic identification of skill weaknesses and related training needs. Review of employee files showed that several GNAs hired for more than a year had no documented performance evaluation within the past year. In an interview, the DON and NHA confirmed there was no established process to ensure annual performance evaluations for nurse aides, resulting in a failure to monitor and assess aide performance as required.
Facility administration permitted a nephrology NP to conduct consultations, including on new admissions, without an executed contract and without required physician orders, in violation of facility policy. One resident’s consult documented a medication error that the NP did not report to staff, and the issue was only identified later by surveyors. Additional residents were also seen by this NP over several months with consult notes uploaded days after visits and no corresponding nephrology orders. The medical director reported that nephrology consults should be based on diagnosed need and attending physician orders, was not overseeing these consults, and confirmed there was no nephrologist signing off on the NP’s work.
Facility staff did not maintain an effective training program for all personnel. Orientation materials lacked behavioral health content based on the facility assessment, and the infection control module omitted the facility’s own infection prevention and control policies and procedures. Multiple GNAs, an LPN, and a laundry aide were not current with required computer-based trainings, including abuse, Resident Rights, and infection control. Corporate assigned annual CBT modules, but there was no system in place at the facility level to ensure staff completed the required education, and leadership could not provide a rationale for these deficiencies.
Facility staff failed to establish and implement a comprehensive nurse aide training program that ensured each aide received at least 12 hours of annual education, including dementia care, abuse prevention, and skills competencies. Review of three aides’ personnel files and computer-based training transcripts showed no documented annual performance evaluations and no evidence of completing the required 12 hours of competency-based training within the past year. The existing nurse aide training plan consisted only of computer-based modules without skills competency components, and leadership staff, including the NHA and acting Nurse Practice Educator, confirmed that a formal nurse aide training program had not been developed or implemented.
The facility failed to timely report multiple allegations of abuse, neglect, and injuries of unknown origin to the State Agency within required timeframes. In separate incidents, a resident reported inappropriate touching, another had a bruise and discoloration to the right knee and shin first identified by family, a ventilator‑dependent resident experienced loud and aggressive behavior and threatening statements from an RT, and another resident reported pain after an improper transfer to a bedside commode. In each case, staff such as a UM, RN, LPN, and other management were aware of the concerns earlier than the times documented in reports to the SA, delayed notifying leadership, or did not escalate the concerns as required, resulting in reports being submitted hours to days after the initial allegations or discovery of injuries.
Staff failed to uphold resident dignity and self-determination when one resident repeatedly and loudly requested help to use the bathroom due to stomach pain and fear of incontinence while an LPN at the nurses’ station acknowledged the need but continued medication tasks and phone use without providing or arranging timely toileting, leaving another staff member to address the ADL need only after a significant delay. In a separate case, a cognitively intact resident with a documented care plan and physician’s order not to be awakened between 11 p.m. and 7 a.m. was disturbed when an RN entered the room while the resident slept and pulled down the covers to check a colostomy bag, and additional TAR orders were scheduled during the no-disturbance period, requiring staff to wake the resident despite the clearly stated preference.
Two residents experienced failures in care and protection when an assigned GNA did not provide any ADL care to a fully dependent, incontinent resident for an entire shift, despite documentation indicating care had been provided, and an RT behaved loudly and aggressively toward a ventilator‑dependent resident, making threatening statements about tying the resident down and "hitting back." An LPN on the ventilator unit, though familiar with the abuse policy, delayed reporting concerns about the RT’s conduct to management, and the incident was not reported to the state agency until several hours after the aggressive behavior began.
A contracted respiratory therapist allegedly intimidated a resident by stating that if a patient hit him, he would hit back, while the resident was agitated and raising hands in a blocking manner. A GNA later heard a loud smack from the room and, upon questioning, was told by an LPN that the therapist had not hit the resident but had clapped near the resident’s ears. Both the GNA and LPN felt uncomfortable but did not immediately remove the therapist from patient care, despite the LPN’s knowledge of the abuse policy and the unit’s ventilator status. Concerns were not promptly reported to the unit manager or DON, resulting in a failure to ensure resident safety by immediately removing the alleged perpetrator from patient care following an abuse allegation.
A resident received a double dose of oxybutynin ER over an extended period due to a medication order error that was not reported or corrected when first identified. A nephrology NP consultant documented that the resident was on a duplicate oxybutynin dose and recommended monitoring for LUTS while not recommending continuation of that drug, but did not notify facility staff or follow up, instead only uploading the consult into the EHR days later. The DON later learned that the NP had chosen not to report the error because she did not want to get anyone in trouble, resulting in the medication error remaining unaddressed.
Physicians and NPs did not consistently enter and upload progress notes and orders at the time residents were seen, resulting in delays and failures in implementing treatment plans. A resident admitted after a fall with rib fractures had a nephrology NP consult that was uploaded days after the visit, and the DON confirmed that nephrology consults and recommendations were not being promptly communicated. The facility NP stated she does not review the MAR and was unaware of the nephrology consult, so a medication error went unidentified until raised by a surveyor. For the same resident, an attending physician’s H&P note, including medication reconciliation and new orders for Oxybutynin discontinuation and Trospium initiation, was completed and uploaded many hours after it was started and the orders were never implemented, leaving the resident on duplicate Oxybutynin. Another resident’s physician note was dated as if the resident had been seen two days before the note was actually created, delaying staff access to any new orders, and the DON reported that multiple physician notes from prior months were also uploaded several days after completion.
The facility failed to ensure GNAs were competent in providing care, as shown by two incidents and missing competency documentation. In one case, a resident who required moderate assistance for toileting per the care plan was left alone on the toilet by a GNA, leading to a bathroom fall after the resident attempted to self-transfer. In another case, a resident with a broken leg reported pain after being transferred by a GNA, who described providing contact guard support by holding the resident’s ankles and later lifting the resident’s legs off the bed, prompting the resident to cry out in pain. Review of both GNAs’ files revealed no evidence of required skills checklists, annual evaluations, or training records, and leadership acknowledged concerns about the lack of training and education.
A resident admitted after a fall with rib fractures and with overactive bladder and BPH was given duplicate oxybutynin ER therapy when staff followed two concurrent orders for 10 mg and 5 mg (2 tabs) every morning, resulting in a total daily dose of 20 mg instead of the single 10 mg dose documented on hospital discharge records and physician notes. The MAR showed both orders were administered over multiple days. A nephrology NP documented the duplicate dosing in a consultation note she uploaded herself but did not notify facility staff, and the DON reported that consultations were expected to be routed through the unit manager or ADON for review and entry.
Facility administration failed to maintain proper oversight and documentation for a nephrology NP consultant, allowing consultations on residents without a timely-uploaded record, without a pre-existing contract, and without alignment between the DON and medical director on when and how the NP should be used. Leadership did not maintain or review a current facility assessment, so needed staff competencies were not defined, and orientation materials omitted required behavioral health content. Multiple clinical and non-clinical staff, including GNAs, an LPN, an RN, an activity assistant, and a laundry aide, had not completed required annual trainings, and the infection control module lacked facility-specific policies. Nurse aide files lacked annual performance evaluations and evidence of 12 hours of competency-based training, and the nurse aide training program consisted only of generic computer modules, with no structured competency validation or educator consistently overseeing completion.
The facility failed to implement an effective process for communication between the governing body and the administrator, including how, how often, and what information should be communicated. The written governing body policy lacked an implementation date and, although it required members to be active, engaged, and involved in facility affairs with direct access to the administrator and compliance officer and participation in QAPI, there was no evidence that governing body members attended QAPI meetings. Documentation identified the administrator as the Compliance and Ethics Officer and the DON, social worker, and medical director as members of the Compliance and Ethics Committee, but QAPI sign-in sheets did not show governing body participation. The NHA reported being unaware of a policy on governing body involvement, confirmed that the governing body had not attended QAPI meetings, and stated that she had not contacted them since her return to the facility.
Facility leadership failed to complete and maintain a comprehensive facility-wide assessment of needed resources for competent resident care. When surveyors requested the assessment, the NHA initially could not locate it and later produced an incomplete “Facility Assessment Tool” that was dated earlier and listed multiple signatories. The NHA acknowledged she had not reviewed or developed a facility assessment since returning to her role, and also reported having had no contact with the governing body during that time, despite the assessment indicating governing body involvement. The deficiency is cross-referenced to F835 and F940.
Facility staff did not ensure that an Infection Preventionist (IP) participated in QAPI committee meetings as required. Review of QAPI meeting sign-in sheets over a 10‑month period showed that an IP did not attend at least quarterly, with half of the reviewed meetings lacking IP attendance. A corporate clinical resource nurse, serving as the acting QA coordinator and IP, reported that no staff member had been formally assigned as an IP during this time frame, resulting in the QAPI group not having all required members.
The facility did not conduct comprehensive investigations into two separate allegations of abuse and neglect. In one instance, a resident with cognitive and physical impairments reported rough care by a GNA, but the investigation lacked interviews about prior behaviors and did not assess if other residents felt unsafe. In another case, after a neglect allegation, only residents able to communicate were interviewed, and non-verbal residents under the same staff member's care were not assessed, leaving the investigation incomplete.
Surveyors identified that multiple residents who required assistance with ADLs, including incontinence care and showers, did not receive the necessary personal care as documented in their records. One resident was left soiled for hours, another received far fewer showers than scheduled, and a third had multiple shifts with no documentation of care provided. Staff interviews confirmed gaps in care and documentation, and discrepancies were found between paper and electronic schedules.
A resident was transferred to the hospital for shortness of breath after experiencing a change in condition. Documentation by an LPN indicated that PRN oxygen was administered, but review of the medical record found no physician's order for the oxygen use. The DON confirmed that no order was entered into the resident's record.
Staff with facial hair, including a dietary aide, the kitchen manager, and the corporate Certified Dietary Manager, were observed preparing and handling food in the kitchen without wearing beard restraints as required by professional standards. The deficiency was acknowledged by the Nursing Home Administrator and the involved staff when brought to their attention.
A binder intended to display the most recent federal survey results was missing these documents, and staff were unaware of the omission until it was pointed out during a survey. The only location for survey results in the facility did not contain the required information, as confirmed by the DON and Regional Nurse Consultant.
A resident who was cognitively intact and responsible for their own medical decisions was not provided with information or opportunities to formulate an advance directive. Review of the medical record and interviews with the Social Services Director confirmed that no documentation or materials regarding advance directives were offered or discussed with the resident.
A resident experienced theft of personal items and cash after the lock on their bedside cabinet remained broken for one to two months, despite repeated reports to nursing staff. The unsecured drawer was observed open with valuables inside, and the resident was unable to secure their belongings. The DON acknowledged the failure to protect the resident's property and the lack of support for filing a grievance.
A resident reported missing hearing aids, but staff failed to initiate or follow the facility's grievance process. The grievance policy lacked identification of a Grievance Official, and staff were unclear about their roles in handling grievances. Although the grievance log showed the issue as resolved, the resident continued to report the hearing aids as missing, and key staff were unaware of the complaint or its resolution.
A resident received multiple doses of PRN Ativan without documentation of attempted non-pharmacological interventions or adequate behavioral indications for use. Nursing staff did not record required information in the eMAR or other available documentation systems, despite clear expectations for such documentation.
Advance directive documentation not maintained in resident record
Penalty
Summary
The facility failed to ensure advance directive documentation was maintained and readily accessible in the resident's medical record for one resident. Staff stated that resident records were maintained electronically in PCC and that advance directive documents other than the MOLST should be located in the Miscellaneous section of the electronic record. Social services staff also stated the resident had an advance directive naming a medical and financial Power of Attorney, as documented in the admission social service assessment. Review of the electronic medical record showed the resident lacked decision-making capacity, with a capacity evaluation signed by the Medical Director, and had hospital discharge orders identifying the resident as No CPR - A2 along with a facility order summary indicating Do Not Resuscitate and Do Not Intubate. Despite confirmation that an advance directive existed, staff were unable to locate it in the electronic record. A paper copy was later provided that had been printed from hospital records, but there was still no evidence it had been incorporated into the facility's electronic medical record. Follow-up review also showed the resident's prior No CPR MOLST had been removed and replaced with a Full Code MOLST, while active orders remained for both Full Code and Do Not Resuscitate/Do Not Intubate, and there was still no evidence the advance directive had been uploaded or maintained in the record.
Failure to Provide Written Grievance Decision
Penalty
Summary
The facility failed to follow resident grievance requirements for a cognitively intact resident with a BIMS score of 15 who had diagnoses including respiratory failure and other conditions requiring nursing care and medication administration. The resident reported repeated medication concerns, including a prior double dose of thyroid medication and multiple close calls involving incorrect medication dosages, and stated that these concerns became serious enough that they filed an official grievance with the facility in June 2026. During the grievance investigation, the facility’s grievance log documented that the resident reported a medication error and that an investigation was initiated, with entries stating that nurse education was provided and that nursing updated the medication order. However, the resident stated they only received verbal feedback from a former unit manager and never received a written grievance decision from the NHA or any written investigation findings. The resident also stated they were not informed in writing whether the medication error was confirmed and were only told that medication instructions had been changed to all capital letters. Review of the facility’s grievance policy required the grievance official to keep the resident apprised of progress and issue a written decision at the conclusion of the investigation that included the steps taken, pertinent findings or conclusions, whether the grievance was confirmed, corrective action taken or to be taken, and the date issued. The facility’s Resident Concern/Compliment Form for the grievance documented the complaint and the response about changing the medication order print, but it did not document the investigation findings, whether a medication error occurred, or that a written decision was provided to the resident. The NHA confirmed that the facility’s practice was to provide grievance outcomes verbally rather than in writing and acknowledged there was no documentation supporting the reported nurse education.
Incomplete investigations of neglect allegations
Penalty
Summary
The facility failed to conduct thorough investigations of allegations of neglect before concluding that the allegations were unsubstantiated for two residents with facility-reported incidents. For one resident, the resident’s daughter alleged that a CNA instructed the resident to go in the brief rather than assisting with toileting or providing a bedpan. The facility’s investigation file included a resident concern form, a nursing home administrator investigative note, and staff statements, but also contained three resident interview and observation assessment forms that were signed, dated, and timed while the interview and observation sections were left blank. The ADON stated that the incomplete forms likely meant licensed nursing staff were expected to complete skin assessments and observations, and later provided two skin assessments, one completed within the required five-working-day timeframe and one completed after that timeframe, with no documentation provided for the third resident assessment. For the second resident, the resident’s sister alleged neglect related to oral hygiene, hair hygiene, incontinence care, nutrition, and staffing. The facility documented notification of the physician, local ombudsman, and law enforcement, and the resident was evaluated by the NP, Psychiatry, Social Services, and nursing staff. The facility concluded the allegation was not verified after documenting that the resident denied neglect and was satisfied with care. However, the investigation file again contained three signed, dated, and timed resident interview and assessment forms for residents on the same hallway, including one form that could not be linked to an identifiable resident, and none of the forms contained completed interview or observation documentation. The ADON acknowledged that the facility could not demonstrate the investigations were completed thoroughly before concluding the allegations were unsubstantiated.
Inaccurate MDS Coding for Antipsychotic and Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident reviewed for unnecessary medications. The resident had an order for Risperdal 0.5 mg at bedtime for delusional disorder, which was active from 1/2/26 until discontinued on 7/7/26, and the May 2026 MAR showed the antipsychotic was administered daily as ordered. However, the MDS with a reference date of 5/15/25 documented in section N0415A that the resident was taking an antipsychotic medication, while section N0450A incorrectly indicated that no antipsychotic medication was received, causing the related gradual dose reduction questions to be skipped. The record also showed an order for tramadol 50 mg every 12 hours for pain, effective since 5/5/26, and the May 2026 MAR showed it was administered as ordered. Despite this, the same MDS assessment documented in section J0100A that the resident did not receive a scheduled pain medication regimen. During interview, the MDS nurse stated the MAR would be used to obtain information for sections N and J, then later stated the medication items in those sections were coded in error and that she would submit a modification. The DON was later informed of the inaccurate coding of regularly scheduled pain medication and antipsychotic medication on the MDS assessment.
Failure to Care Plan Hearing Aid Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with hearing aid needs. Review of the medical record showed that an MDS with an ARD of 11/12/25 indicated the resident did not have a hearing aid at that time, but a Hearing Aid Delivery Receipt dated 12/8/25 documented delivery of left and right hearing aids. A later order dated 1/2/26 directed nursing staff to place the hearing aids in the resident’s ears every morning, remove them in the evening, store them in the med cart, and ensure the battery door was open when placed in the case. Another MDS with an ARD of 2/12/26 indicated the resident had a hearing aid at the time of that assessment. A subsequent MDS with an ARD of 5/15/26 identified the resident as cognitively intact with a BIMS score of 15 out of 15 and again indicated the resident had a hearing aid. During interview, the resident stated they could hear okay out of one ear but that the hearing aid for the other ear had been lost about a month earlier and that they had spoken to someone at the facility about it but had not received any updates. The UM reported that both hearing aids were currently gone. Review of the resident’s care plans, revised 5/14/26, did not reveal documentation addressing the resident’s need for or use of hearing aids.
Failure to Hold Required Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to ensure that care plan meetings were conducted following completion of MDS assessments for one resident reviewed for unnecessary medications. The resident’s record showed an interdisciplinary care plan meeting was held in December 2025, but a quarterly MDS with an ARD of 2/17/26 was completed on 2/26/26, and a progress note that same day documented that a care plan meeting had been scheduled but the resident wanted to reschedule it. The note stated the meeting would be rescheduled late the next month per the resident’s request. Further review of the record failed to show documentation that a care plan meeting was scheduled or held in March or April 2026. A later quarterly MDS with an ARD of 5/20/26 was completed on 6/15/26, and a progress note on 5/29/26 stated the care plan meeting was rescheduled due to a doctor’s appointment. On 7/9/26, the record still did not show that a care plan meeting had been held since December 2025. When asked about rescheduling, the DSS stated another meeting would be scheduled based on when family and others were available, and on 7/10/26 the DSS and SSD presented a letter showing a care plan meeting was scheduled for 7/21/26. The SSD confirmed there had been no care plan meeting for the resident since December. The DON was later informed that no interdisciplinary care conference had been held following the MDS assessments and that no meeting had occurred for more than 6 months.
Inaccurate Documentation of Hearing Aid Care
Penalty
Summary
The facility failed to ensure staff accurately documented the provision of care for a cognitively intact resident with a BIMS score of 15 out of 15. The resident had an order for nursing staff to place hearing aids in the resident’s ears every morning, remove them in the evening, store them in the medication cart, and ensure the battery door was open when placed in the case. Review of the MAR showed a documentation area for hearing aids at 9:00 AM and 9:00 PM, and staff documented provision and storage from June 1 through June 12. On 6/12/26, a nurse documented that the hearing aid was stored in the medication cart, but the morning documentation on 6/13/26 was blank and the evening entry was marked with a 7, which indicated Other/See Nurse Notes. The corresponding nursing note was not available. The resident later reported that the hearing aid had been in a cup and was now missing, and the SSD was unable to locate it. A nurse later confirmed removing the hearing aids and placing them in a cup on the medication cart but could not confirm they were secured in the locked medication cart before the end of the shift. Despite the hearing aids being missing, staff continued documenting that they provided the hearing aids and secured them in the medication cart on multiple subsequent dates.
Failure to Provide Timely Incontinence and ADL Care
Penalty
Summary
The facility failed to provide necessary ADL care, including timely incontinence care, for a resident with a history of cerebral infarction (stroke), urinary incontinence, irritable bowel syndrome, and other medical conditions requiring assistance with personal care. The resident reported that they had used the call bell for incontinence assistance during the 11-7 shift and that a GNA said someone would come help, but no one returned. A facility-reported incident was submitted stating the resident complained they were not changed all night during the 11-7 shift. The facility investigation file included a skin assessment showing new red areas to the right and left buttocks and sacrum, and a change in condition note stating the redness began on 6/9/26. A Social Services Designee stated the resident alleged they were not changed, while one GNA denied answering the call bell and another GNA stated the resident reported not being changed all night and that no one returned after help was requested. The surveyor found no evidence that the facility reviewed GNA task documentation to determine whether ADL care was provided during the 11-7 shift, and the investigation did not address the skin assessment or change in condition documentation. Later review of task documentation showed personal hygiene, toilet transfer, and turning/repositioning were documented just after midnight, with no bladder documentation during the 11-7 shift and no further documentation of incontinence care until nearly 1:00 PM the next day. The DON reviewed the documentation and confirmed the resident was not changed, turned, or dried after midnight until the next shift.
Failure to Provide Planned Activities
Penalty
Summary
The facility failed to ensure activities were provided as indicated in the care plans for two residents with dementia and significant cognitive impairment. Resident #10 had a history of stroke, was dependent on staff for transfers and mobility, and had a care plan noting a preference for blues and jazz music, including live performances and radio. During observations, the resident was seen in the room with the television on and did not respond to a surveyor greeting on one occasion. Activity documentation for the reviewed period showed television documented as the activity on multiple dates, but there was no documentation that music was provided or offered during the 60 days reviewed. Resident #7 had severe cognitive deficits and dementia, and the MDS identified music as very important and religious services as somewhat important. The care plan stated the resident enjoyed blues, jazz, 60's, and 70's music and that church was important, with Baptist services able to be watched on TV as interested. The resident was observed in bed with the television on and speaking loudly with no staff or visitor present. Activity documentation again showed television as the activity on multiple dates, but there was no documentation that music was provided or offered during the 60 days reviewed, and no documentation that the resident was offered attendance at religious services or visited by religious providers despite the activity calendar listing church services and Baptist church providers.
Failure to Rotate Insulin Sites and Report Change in Condition
Penalty
Summary
The facility failed to ensure rotation of insulin injection sites for residents receiving multiple daily insulin injections. Resident #7 had diagnoses of diabetes, dementia, and severe cognitive impairment, with a BIMS score of 1 out of 15. The resident had orders for daily Lantus insulin and Lispro insulin three times daily with meals. Review of the medication administration record showed repeated injections given in the same sites over multiple days, including multiple Lispro injections in the right arm and right lower quadrant of the abdomen, followed by repeated injections in the left arm and left lower quadrant of the abdomen. Resident #59 had multiple sclerosis, diabetes, and required assistance with activities of daily living. The resident had a BIMS score of 15 and was receiving insulin with blood glucose monitoring twice daily. The resident and spouse reported concerns about how insulin was being administered, including a nurse attempting to give an injection across the resident's body rather than walking around the bed. Record review showed repeated insulin injections documented in the left arm on consecutive days, with Lantus also documented in the left arm on several days and Lispro documented in the left arm three times on multiple days. The facility also failed to report a resident's change in condition to nursing supervision. Resident #19 had a BIMS score of 15 and required staff assistance with ADLs, including bathing and showering. The resident reported that during a shower, a GNA was rough while washing the resident's feet, and the skin between the toes on both feet split and bled. The incident investigation included statements that the GNA saw blood between the resident's toes and told another GNA she would report it to the nurse, but the nurse stated no report was made to her regarding the bleeding toes. The NHA acknowledged that the GNA observed the bleeding toes but did not report the change in condition to the charge nurse.
Failure to Maintain and Track Resident Hearing Aid
Penalty
Summary
The facility failed to address a resident’s hearing aid needs for a cognitively intact resident with a BIMS score of 15 out of 15 and an MDS indicating the resident had a hearing aid. The resident’s care plan did not include documentation regarding the need for or use of hearing aids. The medical record also showed an order for nursing staff to place the hearing aids in the resident’s ears each morning, remove them in the evening, and store them in the medication cart. Staff documentation showed the hearing aids were being placed and stored through part of June, but documentation became incomplete on 6/13/26, with a blank morning entry and an evening entry coded as “Other/See Nurse Notes,” and the corresponding nursing note stated “Not available.” A resident concern form dated 6/15/26 documented that the resident reported the hearing aid was in a cup and then missing, and that Nurse #27 was unable to find it during the morning shift. The Social Service Designee followed up but was unable to locate the hearing aid. Interviews and record review showed conflicting and incomplete communication about the missing hearing aid and audiology follow-up. A nurse reported removing the hearing aids and placing them in a cup on the medication cart but could not confirm they were secured in the locked cart. The ADON stated the audiology provider had not been informed of the missing hearing aids and that the resident would be added to a list when the facility had confirmation of the provider’s next visit, while also stating there was no specific running list. The DON later reported there was no documentation that the audiology provider had been notified of the missing hearing aid, and surveyors cited the failure to ensure the hearing aid was available and the failure to ensure the audiology provider was notified of the loss.
Resident Struck by Hoyer Lift During Transfer
Penalty
Summary
The facility failed to protect a dependent resident from injury while using a Hoyer lift. Resident #59 had Multiple Sclerosis and required assistance with ADLs; the care plan directed that transfers be completed with a mechanical lift and two staff members. During the incident, GNA #39 brought the Hoyer lift into the resident’s room while the resident was seated and awaiting transfer back to bed. As the lift was moved forward, the top portion swung and struck the resident above the eyebrow/eye, causing a cut. The resident reported that the aide was rushing and rough during care, and the resident’s spouse stated they had concerns about the aide’s careless behavior. The facility’s investigation documents showed inconsistent accounts of the event, but multiple statements confirmed that the resident reported being hit by the lift and that GNA #39 later acknowledged the lift bumped the resident’s forehead while she was rushing and not being careful. The ADON confirmed that all residents transferred with a Hoyer lift require two staff members and stated that GNA #39 was rushing and thinking about the next task when the resident was struck. The surveyor also confirmed that the resident was not protected from injury due to staff rushing while handling the mechanical lift equipment.
Hemodialysis Medication Administration Without Orders or Communication
Penalty
Summary
The facility failed to ensure safe, appropriate hemodialysis-related medication management for two residents receiving scheduled hemodialysis. The report states that the facility policy required physician orders for hemodialysis to include instructions about medications to be given or withheld before treatment, and required nursing staff to communicate medication administration to the hemodialysis provider and document those communications. Staff also stated that it was the first facility in 34 years of nursing where residents receiving hemodialysis routinely received scheduled morning medications before leaving for dialysis appointments. For one resident, the record showed scheduled morning medications were documented as given immediately before hemodialysis on multiple occasions, but there was no physician or consulting nephrologist order authorizing that practice, no documentation in the hemodialysis communication binder that medications had been communicated to the dialysis provider, and incomplete or inconsistent departure documentation. For the second resident, the MAR likewise showed scheduled morning medications were administered immediately before hemodialysis on multiple occasions, the hemodialysis communication record was incomplete on one date, and staff confirmed there was no written order directing that medications be given before dialysis and could not identify who authorized the practice. Both residents’ care plans addressed hemodialysis care, but neither contained a physician-directed intervention specifying that scheduled morning medications should be administered before treatment.
Pharmacy Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to have an effective system to ensure monthly pharmacy medication regimen review recommendations were addressed by providers in a timely manner. The Director of Nursing stated that the pharmacist’s recommendations were given to unit nurse managers to review with the physician or nurse practitioner, and that the paper recommendation form would be scanned into the EHR and kept in a binder. However, review of the binder and medical records showed that pharmacist recommendations were not consistently documented in the chart or shown to have been reviewed and addressed by the appropriate providers. For one resident receiving Quetiapine 25 mg at bedtime, the pharmacist documented a medication regimen review and recommended considering a gradual dose reduction to Quetiapine 12.5 mg at bedtime unless clinically contraindicated. The medical record did not contain documentation that the initial recommendation was addressed by the primary care provider. A later pharmacist review repeated the same recommendation, and the form in the EHR showed the nurse practitioner referred the matter to psychiatry. The psychiatric NP agreed with the recommendation and entered an order to discontinue the 25 mg dose and start 12.5 mg at bedtime, but the facility did not provide documentation that the original recommendation had been reviewed by the primary care provider or psychiatric provider before survey exit. For another resident, the pharmacist recommended discontinuing Melatonin after citing concerns from an observational cohort study about long-term use and cardiovascular outcomes. The nurse practitioner documented only a referral to psychiatry. The psychiatric NP later saw the resident on two occasions and documented that the resident was taking Melatonin for a sleep cycle disorder, along with trazodone and Xanax, and included a generic statement that a GDR was not indicated because it would decrease quality of life. Those notes did not show awareness of the pharmacist’s recommendation to discontinue Melatonin, and when interviewed, the psychiatric NP stated the recommendation had never been addressed with her and that she had not reviewed it.
Unnecessary Medication Administration and Failure to Follow PRN and Insulin Parameters
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary drugs. For one resident, an order for oxycodone 5 mg every 8 hours as needed for pain rated 8 to 10 was in effect, but the medication was administered on multiple occasions when the documented pain score was below 8, including scores of 6, 3, 4, and 5. The MAR included a place to document pain level and the time the medication was given, and nurse progress notes showed follow-up pain scores after administration, but the record did not consistently show that the resident met the ordered pain threshold before receiving the narcotic. The record also showed that non-pharmacological interventions were not documented before several PRN oxycodone doses. Although a nurse stated she would massage the resident and provide a pain patch before giving the medication and said these interventions were documented, the MAR and other records did not show documentation of non-pharmacological measures before the doses given on multiple dates. In addition, a controlled drug sheet showed one oxycodone dose removed from supply, but the medical record did not show that the resident was in pain or requested medication at that time, and no documentation was found to show the dose was actually administered. For another resident, there was an order for blood sugar checks before meals and at bedtime and an order for insulin lispro 3 units with meals, to be held if blood sugar was less than 100. The MAR showed several occasions when blood sugar readings were below 100, yet the insulin was still administered at the corresponding meal times. A nurse practitioner confirmed the medication was supposed to be held when the blood sugar was below the parameter, but the insulin was still given on multiple occasions despite the hold order.
Missing Abnormal Lab Results in Resident Record
Penalty
Summary
The facility failed to ensure abnormal laboratory results were uploaded into a resident’s electronic medical record in a timely manner. Resident #48, a frail and elderly resident admitted in January 2026 with multiple medical conditions including pressure ulcer and hyperkalemia, had two nurse practitioner progress notes on 7/08/26 that conflicted regarding treatment for elevated potassium. One on-call NP note documented review of a potassium result from 6/29/26 that was normal and gave an order to hold sodium polystyrene sulfonate because the medication was not available from the pharmacy, while another NP note documented that the resident had high potassium levels on 7/06/26 and 7/08/26 and ordered continuation of sodium polystyrene sulfonate and another medication used to treat high potassium. A review of the miscellaneous scanned documents showed the most recent lab result in the record was from 6/29/26, and the lab reports for 7/06/26 and 7/08/26 were not in the resident’s chart when reviewed. During interviews, staff searched for the missing lab reports but could not locate them in the record. The DON explained that the hospital did not automatically transmit lab results and that only the ADON had access to retrieve them from the hospital portal, after which they were printed, reviewed, and then scanned into the resident’s medical record by the receptionist. Staff acknowledged that the abnormal lab results were available at the facility but were not placed in the resident’s record when the on-call provider reviewed the chart, and they could not explain why the most recent lab results were missing.
Failure to Follow Up on Dental Referral
Penalty
Summary
The facility failed to follow up on a resident’s need for oral surgery. Resident #11, who was admitted in May 2024 for assistance with all activities of daily living and had diagnoses including acute and chronic respiratory failure and diabetes, reported during interview that a dentist had told him/her that teeth needed to be pulled, but no appointment had been scheduled. A review of the resident’s record showed a dental consult/exam/visit note dated 2/06/26 recommending referral to an oral surgeon for surgical extraction of retained roots and listing a company name and phone number for the referral. During interview, the ADON explained that when dental paperwork indicated a need for follow-up, the unit manager was expected to contact the facility scheduler by email and in the communications section of the medical record software, but this information was not part of the clinical record. The ADON stated she did not know whether the scheduler had been informed of Resident #11’s need for an oral surgeon appointment and said the unit manager for that unit was no longer at the facility. She also stated she was not aware of the resident’s need for follow-up with an oral surgeon.
Failure to Have a Qualified Food Service Director
Penalty
Summary
Failure to employ a qualified food service director was identified after surveyors reviewed facility documentation and interviewed staff. During the kitchen tour, Staff #15 identified himself as the Dietary Manager but stated he was not a Certified Dietary Manager (CDM) and that his boss had the CDM. He also reported that the CDM was at the facility only two to three times per week and that a dietitian was present four days per week. The facility’s registered dietitian later confirmed that she worked four days a week and that her role was to coordinate with the Dietary Manager regarding diet textures and supplements, but she had no oversight or management of the kitchen. The Nursing Home Administrator later provided a CDM certificate for Staff #47, but the administrator stated that Staff #15 was the Dietary Manager and that Staff #47 was a corporate employee who was only at the facility one to two days per week. Staff #47 confirmed he was at the facility once or twice per week. The administrator stated he believed this arrangement was acceptable because the facility had a full-time RD. Surveyors reviewed state requirements showing that in Maryland, a nursing home with more than 50 beds must assign overall supervisory responsibilities for food service and food production to a full-time qualified dietetic service supervisor, and no additional documentation was provided by survey exit to show the RD worked full time or had managerial duties in the kitchen.
Menus Not Followed for Pureed Meal Service
Penalty
Summary
Menus were not followed for a pureed meal service, as shown during observation of the dinner tray line when three pureed items were identified by the cook as mashed potatoes, spinach, and turkey. The dinner menu for 7/9/26 listed winter blend vegetables and baked macaroni and cheese, and neither spinach nor mashed potatoes appeared on the dinner menu or the alternative menu. Corporate Chef #47 confirmed that the pureed vegetable for dinner was spinach and stated that spinach had also been served at lunch, and that mashed potatoes were being served instead of macaroni and cheese for better consistency. A taste test of the pureed dinner confirmed the items were spinach, mashed potatoes, and turkey, while the regular consistency meal contained winter blend vegetables made up of broccoli and cauliflower and included macaroni and cheese. On 7/13/26, Resident #41's family reported concern that the resident required pureed food and did not get the same food as everyone else, stating that the food had been all white on the meal tray on occasion. The resident's medical record showed a diet order for pureed texture in place since 6/26/26.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety. Surveyors observed a cutting board along the tray line with multiple cut marks and orange stains on both sides, and the Corporate Chef acknowledged the condition of the board. Surveyors also observed cups in the dishwashing area and near the tray line being stored open side down on flat trays while still wet inside, and the Corporate Chef validated that some of the cups contained water. Surveyors further observed an ice machine in the 300-unit nourishment room with reddish buildup and several black splotches on the inner aspect of the door. The Maintenance Director stated maintenance cleans the part of the machine that produces the ice, while the Dietary Manager stated dietary staff does not clean the unit ice machine. In addition, the nourishment room refrigerator contained several unlabeled, undated containers of food, despite the facility policy requiring outside food needing refrigeration or freezing to be labeled with the resident's name and date and stored separately from facility food.
Incomplete and Conflicting Resident Records
Penalty
Summary
The facility failed to ensure MOLST forms were voided and retained in the resident record and failed to maintain complete and accurately documented medical records. For Resident #94, the electronic medical record contained conflicting code status information: an active MOLST dated [DATE] signed by a CRNP indicated NO CPR, while physician orders listed FULL CODE, and a later hospital MOLST signed by a hospital physician indicated Attempt CPR. The newer MOLST was scanned into the miscellaneous section of the EMR, but the prior MOLST was not voided when the resident was readmitted with the new form. Staff interviews confirmed the record contained two active, conflicting MOLST forms, and the DON and Corporate Nurse described a process in which old MOLSTs were deleted from the EMR and kept in a social work binder rather than retained in the resident’s active or archived medical record. The facility also failed to maintain accurate documentation related to Resident #10’s fall and transfer to the hospital. The resident sustained a fall and was sent out for evaluation, and an eInteract change in condition evaluation form was later struck out by the ADON as incomplete, although the ADON stated she was not sure why it had been struck out and believed it may have been done in error. The form contained vital signs, including blood pressure, pulse, and respirations obtained at 11:17 AM, and the ADON and DON were unable to explain why the assessment had been crossed out. Further review showed the SNF/NF to Hospital Transfer Form documented a call to the emergency room nurse at 11:42 AM, while other documentation indicated the resident was not sent to the hospital until later that evening. The hospital discharge paperwork was printed at 7:46 PM, and a physician note documented a return from the ER that evening. The transfer form’s key clinical information section also displayed vital signs dated the next day at 8:00 AM rather than the vital signs recorded on the change in condition form, including a low blood pressure of 83/63. The DON stated the system pulled the most recent vital signs and was unsure why it had selected values from the next day.
Failure to Identify and Repair Environmental Damage in Resident Rooms
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by environmental deficiencies in two resident rooms on a specified unit. During a complaint survey assessing rooms affected by a faulty sprinkler system, the surveyor observed a water-stained ceiling tile in one resident room and damaged drywall behind Bed B in another resident room. The Maintenance Director reported that resident rooms are checked through weekly and monthly audits and that staff are expected to submit work orders in the TELS system for maintenance concerns, but no work orders had been received regarding the stained ceiling tile or the damaged drywall. The DON also stated they did not think a work order had been submitted for these issues. A GNA reported not noticing the damaged drywall in the affected room, and an RN stated they did not pay attention to maintenance concerns during their morning rounds, indicating that staff did not identify or report the observed environmental damage. These observations and interviews show that despite existing audit routines and reliance on staff-generated work orders, the stained ceiling tile and damaged drywall in the residents’ rooms were not recognized or reported by nursing or maintenance staff, resulting in the continued presence of these environmental deficiencies in occupied resident rooms.
Failure to Clarify and Complete IV Fluid Order
Penalty
Summary
Facility staff failed to clarify and accurately implement an IV fluid order for a resident treated for dehydration. Record review showed that on 02/11/26 at 10:57 a.m., the resident was ordered Lactated Ringers 1 liter IV at 75 ml/hour for 2 days. The medication administration record indicated the fluids were signed off as given on 02/11/26 and 02/12/26, but there was no documentation verifying that IV fluids were administered on 02/13/26. During interview, the DON stated the resident was supposed to receive 2 liters in 24 hours and then 1 liter the following day, and that the whole order was intended to cover 2 days, with 2 liters the first day and 1 liter the second day. The DON acknowledged the order was poorly written and confusing, and that staff did not clarify the order. A progress note written by the NP on 02/11/26 at 12:07 p.m. documented that the resident was started on Lactated Ringers IV at 75 cc/hour for 2 liters on 02/11/26 and that IV fluids were to continue for 48 hours. In a subsequent interview, the NP stated they were uncertain how the order was transcribed and, when informed that their note indicated IV fluids for 48 hours beginning on 02/11/26, the NP stated that this note was a typo and that when the nurse started a new bag of IV fluids, a new order was written in error. These discrepancies and lack of clarification resulted in the resident not receiving the full course of IV fluids as ordered.
Failure to Initiate Timely Wound Assessment and Treatment for Multiple Foot Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple left foot wounds received timely and appropriate wound care and treatment upon admission. The hospital discharge summary documented talar osteomyelitis of the left foot, with wound care having applied a dry sterile dressing and kerlix and a plan to consult the resident’s podiatrist, but did not list any additional wounds or specific treatment orders. On admission, the facility’s nursing admission note identified a scab on the left ankle, a sore on the left foot, and a sore on the left heel. Despite these findings, there were no corresponding wound treatment orders in the medical record. The attending physician completed a history and physical on the day of admission, repeating the hospital’s osteomyelitis note, documenting no rashes, lesions, or nodules on skin exam, and not mentioning the additional wounds identified by nursing or initiating any wound treatment orders. Wound care notes showed that the wound nurse practitioner did not first see the resident until 10 days after admission, at which time the resident was found to have a venous ulcer on the left medial malleolus, a left plantar diabetic foot ulcer, and an unstageable pressure ulcer on the left heel, and treatment was then started. The attending physician later stated that he had not assessed the resident’s left foot wounds or provided treatment orders because a wound specialist manages wounds and that he did not have time to see the resident for wound care. The DON stated that the admitting nurse should have read the discharge instructions, clarified the wound order mentioned, and notified the physician to obtain orders for the other two wounds identified on admission. The surveyor was unable to interview the admitting LPN, who had been terminated due to concerns with nursing care.
Failure to Identify and Manage Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to identify a cognitively impaired resident as an elopement risk and to implement interventions to prevent elopement, resulting in the resident leaving the building unsupervised. The facility had an elopement and wandering policy requiring residents to be assessed for elopement risk on admission and throughout their stay, with high‑risk residents to receive an alarm bracelet and an individualized care plan. On admission, the nursing elopement assessment for this resident was completed by an LPN, who marked the resident as unable to ambulate; this locked the remainder of the elopement assessment and resulted in the resident being deemed not at risk for elopement. This determination was made despite hospital records showing that prior to admission the resident had been living at home, driving, and working, and that during the hospital stay the resident could ambulate with a rolling walker and assistance. Following admission, multiple clinical findings and events indicated that the resident’s condition and behavior had changed in ways relevant to elopement risk, but the facility did not reassess the resident for elopement until after the elopement occurred. Progress notes documented that the resident fell twice in the early morning of one day when attempting to get out of bed and walk, with staff noting the resident was unsteady. A care plan was initiated for noncompliance with using a walker. A Brief Interview for Mental Status determined the resident had severe cognitive impairment, and both the attending physician and a nurse practitioner documented that the resident was incapable of comprehending information and making decisions due to a hemorrhagic stroke. Therapy notes showed that the resident’s mobility improved, including ambulating 70 feet with a rolling walker and minimal assistance, which constituted a change in condition. Staff interviews later revealed that the resident frequently talked about going home, became more worked up when family prepared to leave, walked unassisted despite being unsteady, wandered without clear purpose, and had poor safety awareness. On the day of the elopement, the resident was observed by the receptionist walking down the hallway carrying a wash basin with items and a shoebox, then exiting through the front door; the receptionist was unsure if the individual was a resident and did not intervene before the resident left the building. The resident’s assigned LPN and GNA reported they were passing dinner trays and checking blood sugars and did not see the resident leave the unit. A visitor arriving for a Thanksgiving event later found the resident lying on the ground in the visitor parking lot in dark, cold weather, still carrying the basin and shoebox. Another LPN leaving the facility also saw the resident on the ground behind a parked car and initially did not recognize the person as a resident until noticing an adult brief. When interviewed, the resident stated they had gone outside to go home. The facility’s own investigation concluded that the resident left the facility, was outside for several minutes, and was found lying in the parking lot, and that staff had not previously identified or care planned the resident as an elopement risk despite documented behaviors and functional abilities that met the facility’s own criteria for elopement risk. The facility’s investigation file also showed that, prior to the incident, staff education on the elopement policy and elopement assessments had been started but not completed for all staff. Interviews with the interim DON and other staff confirmed that elopement assessments were expected on admission, quarterly, and with changes in condition or behavior, and that the resident’s behaviors—such as repeatedly talking about going home, packing belongings, and exit‑seeking—should have triggered reassessment. The NHA acknowledged that the resident was not being monitored as an elopement risk because the admission assessment had categorized the resident as not at risk, even though the NHA identified behaviors like wanting to go home and packing belongings as high‑risk indicators. These combined assessment failures, lack of reassessment after clear changes in condition and behavior, and lack of effective supervision and response to observed exit‑seeking behavior led to the resident’s elopement and subsequent fall in the parking lot, where the resident sustained an abrasion to the right side of the face and scrapes on both hands.
Removal Plan
- Resident #6 no longer resides in the facility.
- Complete updated elopement evaluations for all current residents to determine if any residents are at risk for elopement.
- Complete updated elopement evaluations by the Unit Managers and DON.
- Recheck alarm bracelets for proper placement and function for all residents determined to be at risk for elopement.
- Place any resident identified at increased risk for elopement on appropriate elopement precautions and update the care plan.
- Educate all facility licensed staff on the elopement policy and procedure, including the elopement risk evaluation process, to ensure elopement risk is reassessed.
- Educate all licensed nurses.
- Educate any licensed staff member unable to attend scheduled education upon arrival to the facility, and ensure education is provided prior to beginning their shift.
- Continue to educate all non-clinical staff on elopement policy and procedures, including identifying elopement risk signs and symptoms and reporting to appropriate clinical staff.
- Educate any facility staff member unable to attend scheduled education upon arrival at the facility, and ensure education is provided prior to beginning their shift.
- Validate education by administering quizzes randomly with 10% of staff weekly.
- Conduct audits monthly.
- Report findings at the monthly QAPI meeting to monitor progress towards improvement and recommendations.
Lack of Annual Performance Evaluations for Nurse Aides
Penalty
Summary
Facility staff failed to ensure that geriatric nursing assistants (GNAs) received annual performance evaluations of their skills, as required to identify weaknesses and provide targeted training. Record review on 1/22/26 showed that GNA #37, hired in 11/2018, had no documented performance evaluation within the last 12 months. Similarly, GNA #14, hired in 2/2019, and GNA #36, hired in 4/2023, also had no evidence of a performance evaluation in the preceding year. In an interview on 1/22/26 at 12:21 PM, the DON and NHA acknowledged that the facility had no process in place to ensure that nurse aides received annual performance evaluations. This deficiency was cross-referenced to F947, indicating it related to training and competency requirements for staff.
Unauthorized Nephrology Consultations Without Orders or Contract Oversight
Penalty
Summary
Facility administration allowed a nephrology nurse practitioner (NP #13) to provide consultation services to residents without an established contract in place and without physician orders authorizing these consultations, contrary to facility policy. For Resident #16, a nephrology consult was completed on 1/13/26 and not uploaded until 1/15/26, and there was no physician order for this resident to be seen by a nephrologist or consultant. Within that consult, NP #13 documented a medication error on the resident’s medication administration record but did not notify facility staff; the error was instead brought to the DON’s attention by the survey team on 1/21/26, eight days after NP #13 identified it. The facility’s policy on Provision of Physician Ordered Services, revised 2/18/25, states that no diagnostic tests or consultation requests will be performed without specific orders from a physician, PA, NP, or CNS in accordance with state law. Further record review of four additional randomly selected residents showed that all had been seen by the same nephrology NP consultant beginning around 11/9/25, with consultation notes uploaded days after the visits and no corresponding physician orders for nephrology consultations. NP #13 was reportedly seeing every new admission based on lists provided by unit managers when she arrived. The facility medical director stated that the process for nephrology consultation should involve residents with a diagnosed need and an order from their attending physician, and acknowledged that the contract for this consultant was not signed until 1/27/26, despite her seeing residents since at least November 2025. He also stated that he was not the resource following up on NP #13’s consultations and that this should be an actual nephrologist, and there was no nephrologist signing off on NP #13’s consultations.
Failure to Maintain Effective Staff Training Program and Ensure Completion of Required Education
Penalty
Summary
Facility staff failed to develop and implement an effective training program for new and existing staff, contracted staff, and volunteers, as required by regulation and based on the facility assessment. Review of the facility’s orientation PowerPoint on 1/22/26 showed that behavioral health topics were not included, despite the requirement that such topics be based on the behavioral health needs identified in the facility assessment for the resident population. Although the list of computer-based training modules included required topics such as effective communication, Resident Rights, Elder Abuse, QAPI, Infection Control, Compliance and Ethics, and Behavioral Health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. During interview, the NHA reported she did not have a copy of the previous NHA’s facility assessment and had not completed a new assessment since returning to the position in 8/2025, resulting in training topics not being aligned with the facility’s assessed needs. Review of individual staff computer-based training transcripts on 1/22/26 showed multiple staff members were not current with required trainings. One GNA had completed only four computerized training modules in 2024, with abuse being the only required topic listed, and had no completed trainings between 2021 and those 2024 modules. An LPN had last completed computerized training modules in 2022, and two other GNAs had not completed computerized training modules since 2024. A laundry aide had not completed Resident Rights training since 2023 and had not completed infection control training that included the facility’s policies and procedures. The Corporate Clinical Resource Nurse, who had served as interim DON and was acting as Nurse Practice Educator, stated that corporate determined and assigned annual computer-based training topics, but the facility had no system to ensure staff actually completed the assigned modules. When these concerns were reviewed with the NHA, she offered no rationale for the deficient practice.
Failure to Implement Required Annual Nurse Aide Training and Competency Program
Penalty
Summary
Facility staff failed to develop and implement a nurse aide training program that ensured each nurse aide received 12 hours of annual training, including competencies and education in dementia care and abuse prevention, and that training addressed weaknesses identified during annual performance evaluations. Record review on 1/22/26 showed that the personnel file for GNA #37, hired in 11/2018, contained no evidence of a performance evaluation or 12 hours of training with competencies in the last 12 months. Similarly, the file for GNA #14, hired in 2/2019, and the file for GNA #36, hired in 4/2023, lacked documentation of a performance evaluation or 12 hours of competency-based training in the last 12 months. Review of computer-based training transcripts for these three GNAs also failed to show completion of 12 hours of training with competencies in the last 12 months. On 1/16/26, review of the facility’s nurse aide training program/plan revealed it consisted only of a list of computer-based training modules and did not include skills competencies. The NHA and Corporate Clinical Resource Nurse Staff #3 confirmed that this list was their nurse aide training program, and the acting Nurse Practice Educator (Staff #13) stated that the facility had not developed and implemented a training program for nurse aides. These findings were cross-referenced with F730.
Failure to Timely Report Allegations of Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse, neglect, and injuries of unknown origin to the State Agency (SA) within required timeframes after staff became aware of them. For one incident, a resident reported to a GNA that someone had been in the room and touched the resident inappropriately at 6:45 AM. The on‑call Unit Manager acknowledged being aware of the allegation before 9:30 AM but did not notify the Nursing Home Administrator (NHA) until 9:30 AM, and the report to the SA was not sent until 10:47 AM. The NHA, who was involved in abuse investigations and review of final reports, could not explain the discrepancy between the time the allegation was known and the time it was reported to the SA. In another incident, an injury of unknown origin involving discoloration and bruising to a resident’s right knee and shin was known to staff earlier than what was reported to the SA. A family member reported a bruise on the resident’s right knee on one evening, and an RN documented this in the progress notes the following day, which would have required reporting to the SA within 24 hours. However, the facility’s investigation file indicated that management did not recognize the injury of unknown origin until two days later in the morning, and the SA was not notified until late that morning. The RN involved stated she knew injuries of unknown origin should be reported to the NP and supervisor and that suspected abuse should be reported to the NHA within 2 hours, but she had no rationale for not reporting this injury when first made aware. The Corporate Clinical Resource Nurse confirmed the RN’s earlier awareness, and the NHA again could not explain the discrepancy in the reported awareness time. Additional deficiencies occurred when staff failed to promptly report allegations of abuse and improper care involving other residents. In one case, a respiratory therapist was documented as having loud, aggressive interactions with a ventilator‑dependent resident, including statements about tying the resident down or sending the resident out, and a statement that patients who hit the therapist would be hit back. A GNA described the resident as anxious with arms up blocking the therapist, and the LPN on the unit acknowledged knowing the abuse policy and recognizing the behavior as inappropriate but only texted the unit manager hours later; the facility did not report the allegation to the SA until approximately five hours after the start of the therapist’s documented aggression. In another case, a resident reported pain and an inappropriate transfer by a GNA during a move to a bedside commode, and the resident’s daughter later called to reiterate the resident’s pain and allegation. Although the GNA was reassigned and management was notified, no further action was taken until two days later when the resident continued to voice concerns and left AMA, and the SA was not notified of the allegation until that same day, well beyond the required reporting timeframe. The NHA acknowledged understanding that this reporting was late.
Failure to Honor Resident Dignity, ADL Needs, and Nighttime Preferences
Penalty
Summary
Facility staff failed to honor residents’ rights to dignity and self-determination by not addressing one resident’s ADL needs in a timely manner and by disregarding another resident’s clearly documented preference not to be disturbed during specified nighttime hours. During a unit tour, a resident later identified as Resident #7 was observed at the nurses’ station repeatedly and loudly requesting assistance to use the bathroom, stating they had stomach pain and did not want to soil themselves. An LPN at the nurses’ station verbally acknowledged that the resident needed a lift and should not stand, but then continued medication preparation and administration, later walking around the station and sitting at the desk on the phone without providing assistance, attempting to soothe the resident, or arranging for timely toileting. The observations showed that Resident #7 continued to call out for help for an extended period, from at least 11:03 AM until 11:15 AM, with visitors also present and concerned, while the LPN did not respond to the resident’s expressed need for toileting and relief of stomach pain. The resident’s care plan included that the resident was known to fixate on going to the bathroom and might sit on the commode without voiding, but the DON acknowledged that this did not excuse the lack of response from the nurse on the day of observation. ADL care was eventually provided at 11:24 AM by another staff member, an RN working in the role of a GNA, who took the resident to their room and placed them on the toilet, indicating a significant delay between the resident’s initial requests and the provision of toileting assistance. In a separate incident, the facility did not respect Resident #4’s documented preference and physician’s order not to be awakened between 11:00 PM and 7:00 AM. The resident had no cognitive impairment per a quarterly MDS and was able to voice needs, and the care plan and a physician’s order both specified that the resident was not to be woken during those hours. Despite this, an RN entered the resident’s room around 6:15 AM while the resident was asleep, pulled down the covers, and inspected the resident’s colostomy bag. Additionally, the Treatment Administration Record contained staff-entered orders scheduled between 11:00 PM and 7:00 AM, including turning and repositioning, catheter care, and administration of fluids, which required staff to wake the resident during the period they had expressly requested and been ordered not to be disturbed. The resident reported wanting staff to empty the colostomy bag before bedtime and stated being fully capable of requesting help when needed, and the unit manager confirmed awareness of the resident’s preference not to be awakened at night.
Failure to Provide ADL Care and Protect Residents From Intimidation and Abuse
Penalty
Summary
A staff member failed to provide required care and maintain respect and dignity for a dependent resident when a GNA assigned to Resident #10 did not provide any activities of daily living (ADL) care for an entire shift. The facility’s investigation documented that the GNA admitted he did not provide care all day, stating he believed the resident was a “no male” caregiver case, despite having signed off in documentation as providing ADL care to this resident on the previous day and earlier in the month. The resident’s MDS, completed shortly after the incident and reflecting the look‑back period that included the date of the allegation, showed the resident was dependent on staff for all ADLs, frequently incontinent of bladder, and always incontinent of bowel. The LPN assigned to the resident that day reported the resident never complained and that she did not notice the resident soiled, even though the MAR showed she had signed for applying powders and creams to multiple body areas that would have required assessment and recognition of any incontinence needing care. Another deficiency involved failure to protect a resident from intimidation and potential abuse by a respiratory therapist (RT). The RT documented that a ventilator‑dependent resident was repeatedly disconnecting from the ventilator and described the resident as combative, suggesting the resident be sent to the hospital if restraints were not used. A GNA present during the interaction reported that the RT was loudly and aggressively demanding help and stated that if the resident was not tied down, the resident would be sent out, and further reported that the RT told the resident that his patients know not to hit him because he hits back. The LPN caring for the resident acknowledged familiarity with the abuse policy and stated she knew the RT should have left but felt stuck due to working on a ventilator unit. She reported that she first texted her unit manager about the RT’s behavior later that afternoon and received only a brief response, and that she did not escalate the concern until the end of the shift, by which time the RT had gone home. The facility officially reported the incident to the state agency several hours after the onset of the RT’s documented aggressive behavior toward the resident.
Failure to Remove Alleged Abusive Respiratory Therapist From Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident safety by immediately removing an employee from patient care following an allegation of abuse or intimidation. A contracted respiratory therapist was alleged to have intimidated a resident by stating, in the presence of multiple staff, "I tell you like I tell all my patients, if you hit me, I hit back." A GNA reported that the resident was agitated and raising hands in a blocking manner, not attempting to hit the therapist, and that the therapist had been loud and agitated throughout the day. The GNA was upset by the incident and believed the nurse had reported the therapist. After the GNA left the room and was in the hall, she heard a loud “smack” sound; when the nurse exited the room, the GNA asked if the therapist had hit the resident, and the nurse responded that he had not, but had “clapped at [resident] ears.” The LPN caring for the resident recalled discussing the situation with the GNA and stated that both were uncomfortable but felt “stuck” because the therapist was the only respiratory therapist available on a ventilator unit. The LPN acknowledged familiarity with the abuse policy and that the therapist should have been removed from patient care but did not do so. According to interview statements, the unit manager documented first being notified of concerns about the therapist at 6:28 PM, which differed from the LPN’s account of earlier notification, and the DON was not notified of the concerns until a later date. The facility’s failure to immediately remove the therapist from resident care upon the allegation of abuse/intimidation and the delay in reporting up the chain of command led to the cited deficiency.
Unreported Oxybutynin Dosing Error Identified but Not Acted Upon
Penalty
Summary
Facility staff failed to ensure that services met professional standards of quality when a medication error involving oxybutynin was not reported or acted upon after it was identified. Medical record review of one resident’s MAR showed that the resident had been ordered and receiving a double dose of oxybutynin chloride ER, 20 mg instead of the intended 10 mg, from 1/9/26 until the date of review on 1/21/26. Oxybutynin is identified in the report as an anticholinergic medication used to treat overactive bladder, with overdose symptoms that may include central nervous system overactivity, rapid heartbeat, high blood pressure, anxiety, headaches, fever, cardiac arrhythmia, vomiting, respiratory failure, paralysis, and coma. Further review of the resident’s medical record showed that a nephrology NP consultant completed a consultation on 1/13/26 and documented that the resident was receiving a duplicate dose of oxybutynin. In that consultation, the NP did not recommend continuation of oxybutynin, unlike two other urinary medications, and recommended monitoring for lower urinary tract symptoms (LUTS). However, the NP did not report the medication error to facility staff, did not follow up on the issue, and only uploaded the consult into the EHR on 1/15/26, two days after completion. In an interview, the DON stated that when she later questioned the NP about why the error had not been brought to anyone’s attention, the NP said she did not want to get anyone in trouble. These actions and inactions resulted in the medication error going unreported and unaddressed for an extended period.
Untimely Physician Documentation and Failure to Implement Treatment Orders
Penalty
Summary
Physicians and NPs failed to complete and upload progress notes and orders to the medical record in a timely manner and did not ensure that care plans and treatment orders were fully reviewed and implemented. For one resident admitted after a fall with rib fractures, a nephrology NP consultation performed on 1/13/26 was not uploaded and available to staff until 1/15/26, and the DON confirmed that this consultant had been uploading her own reports days after seeing residents, with recommendations not being communicated. The unit manager described a new process in which the nephrologist enters their own orders and uploads their own consults, and also stated that the facility had not been receiving anything directly from nephrology for about two months. The facility NP reported that she does not review the MAR, was unaware that the resident had a nephrology consult, and therefore did not identify a medication error until it was brought to the DON’s attention by the surveyor. For the same resident, the attending physician began a history and physical note on 1/12/26 but did not complete and sign it until 1/13/26, making it available about 36 hours after initiation. That note documented reconciliation of medications and included an order to discontinue a 10 mg dose of Oxybutynin while continuing two 5 mg tablets, and to start Trospium for overactive bladder; however, these changes were not implemented, and the resident continued on a duplicate Oxybutynin dose until 1/21/26. For another resident, the attending physician entered an effective date indicating the resident was seen on 1/12/26, but the note was not created and available in the record until 1/14/26, delaying access to any associated orders. The DON acknowledged that there were multiple physician notes from prior months that were uploaded days after completion and that the attending physician involved no longer worked at the facility.
Failure to Ensure GNA Competency in Resident Transfers and Toileting
Penalty
Summary
The deficiency involves the facility’s failure to ensure that GNAs possessed and demonstrated appropriate competencies for safe resident care, as evidenced by two resident incidents and missing competency documentation. In the first case, a resident who, according to the care plan, required moderate assistance of one staff member for toileting was left alone on the toilet by the assigned GNA. The resident attempted to transfer independently from the toilet and fell in the bathroom, which was the second fall within a week while attempting to use the toilet. The facility’s fall investigation, reviewed with the DON, confirmed that the GNA did not follow the resident’s care plan by failing to remain with and appropriately transfer the resident. Review of this GNA’s employee file showed no annual evaluations of skill sets or online training, and the acting Corporate Clinical Resource Nurse/NPE/IP/QA nurse stated she was not aware of where employee certificates were kept and did not provide additional documentation. In the second case, a facility-reported incident involved a resident with a broken left leg who complained of pain after being transferred by the assigned GNA. The resident reported pain to the nurse and stated they had been inappropriately transferred, and an investigation was not initiated until the resident’s daughter later called to report ongoing pain and the allegedly improper transfer to a bedside commode. During the facility’s investigation, the GNA reported that during the first transfer back to bed, she provided contact guard support by holding the resident’s ankles, and during a second transfer, she lifted the resident’s legs off the bed, at which point the resident began yelling that they were being hurt. Review of this GNA’s personnel file showed that, although she had been hired months earlier, there was no new-hire skills checklist or annual evaluation of GNA skills. The DON acknowledged concerns about the lack of training and education, and these concerns were presented to facility leadership during the survey.
Failure to Prevent Duplicate Oxybutynin Therapy
Penalty
Summary
Facility staff failed to ensure a resident’s drug regimen was free from unnecessary drugs by administering duplicate oxybutynin therapy over a sustained period. Medical record review showed that the resident was admitted after a fall with rib fractures for monitoring of routine healing and also had diagnoses of overactive bladder and benign prostatic hyperplasia. Review of the physician orders and MAR revealed two concurrent orders: Oxybutynin Chloride ER 5 mg (2 tablets) every morning for bladder spasms and Oxybutynin Chloride ER 10 mg every morning for urinary retention, both signed out by staff from 1/9/26 through 1/21/26. Review of the hospital discharge records and physician notes showed only a single intended order for Oxybutynin 10 mg daily, not a total of 20 mg per day. Further review of the resident’s medical record identified that a nephrology consultation completed at the facility by a consultant NP documented that the resident was receiving a duplicate dose of oxybutynin. The consultant NP uploaded her own consultation report with recommendations days after the visit. The DON stated that consultations should go to the unit manager or ADON for review and then be entered by them, and it was reviewed with the DON that the nephrology consultant was uploading her own reports. The DON later reported that the NP acknowledged identifying the medication error but did not bring it to anyone’s attention, stating she did not want to get anyone in trouble.
Deficient Administration of Consultant Services, Facility Assessment, and Staff Training
Penalty
Summary
Facility leadership failed to ensure appropriate conditions and oversight for a nephrology nurse practitioner (NP) consultant who had been seeing residents since November 9, 2025. At least five residents had nephrology consultations documented starting January 21, 2026, but the completed consultation notes were not uploaded into the medical record for several days, even when they contained recommendations or concerns. The DON reported that the NP would be seeing all new admissions and all residents with kidney disease, while the medical director stated that the consultant was not to see every new admission and that a physician order and an actual nephrologist following behind the NP were required. During the survey, it was identified that there had been no contract in place during the months the NP had been seeing residents, and the contract produced by the NHA was signed only the day before, demonstrating a lack of an established, consistent process for use of this consultant. The facility did not have an accessible, current facility-wide assessment to determine needed resources and staff competencies. When surveyors requested the facility assessment, the NHA was unable to locate it and had to request it from corporate, and she acknowledged she had not reviewed the assessment since assuming her role on August 25. As a result, the training and skill sets required for staff to care for the resident population had not been determined. Review of the orientation PowerPoint showed that required behavioral health training was not included, and personnel files for an LPN, an RN, an activity assistant, and multiple GNAs showed they were allowed to care for residents without having completed the required behavioral health training. Further review of the facility’s training program revealed that while computer-based modules existed for required topics such as effective communication, resident rights, elder abuse, QAPI, infection control, compliance and ethics, and behavioral health, the infection control module did not include the facility’s own infection prevention and control policies and procedures. Training transcripts showed that several GNAs, an LPN, and a laundry aide had not completed required annual trainings or had significant gaps since prior years. The acting NPE stated that although a training process was in place, no one was ensuring timely completion, and these staff continued to work. Additionally, nurse aide files for multiple GNAs lacked evidence of annual performance evaluations and 12 hours of training with competencies in the last 12 months, and the nurse aide training program provided by the NHA consisted only of a list of computer-based modules without competency components. The acting NPE confirmed that the facility had not developed and implemented a nurse aide training program based on evaluations, and the NHA acknowledged there was no consistent person in the educator role.
Failure to Implement Effective Governing Body Communication and QAPI Involvement
Penalty
Summary
The facility failed to establish and implement a process for communication between the administrator and the governing body, including the mode of communication, frequency, and content of what was to be communicated. Review of the Governing Body Policy and Procedure showed no implementation date and stated that governing body members were to be active, engaged, involved in facility affairs, have direct access to the administrator and compliance officer through executive board sessions, and be involved in the QAPI program. A letter designated the administrator as the Compliance and Ethics Officer and identified the DON, social worker, and medical director as members of the Compliance and Ethics Committee. However, review of QAPI meeting sign-in sheets showed no evidence that any governing body member attended these meetings. In an interview, the NHA stated she was not aware of a policy regarding governing body involvement with the facility, reported that governing body members had not attended QAPI meetings, and acknowledged she had not contacted them since her return to the facility.
Failure to Complete and Accurately Document Required Facility Assessment
Penalty
Summary
Facility leadership failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources for competent resident care during routine operations and emergencies. On 1/16/26 at 10:55 AM, the Nursing Home Administrator (NHA) was informed that an extended survey was being conducted and was asked to provide the Facility Assessment. During an interview later that day at 12:21 PM with the NHA and the Nurse Educator/Infection Preventionist, the NHA stated she was unable to locate the assessment and needed to request it from the corporate office. When asked if she had reviewed or developed a facility assessment since assuming the position in 8/2025, she reported that she had not. At 1:30 PM on the same day, the NHA provided a document titled “Facility Assessment Tool,” dated 1/5/26, which indicated it had been completed by the NHA, Medical Director, Governing Body representative, and others; however, review showed it was incomplete. In a subsequent interview at 1:46 PM, the NHA confirmed she had not reviewed or completed a facility assessment until the surveyor requested it on 1/16/26, initially explaining this by stating she started in the position in 8/2025, although it was later reported she had previously served as the facility’s NHA from 2020–2024. In a later interview on 1/20/26 at 3:17 PM, the NHA reported she had not been in contact with the governing body since returning in 8/2025, meaning she could not have obtained input from a governing body member as documented on the assessment provided to the survey team. Cross references were made to F835 and F940.
Failure to Ensure Infection Preventionist Participation in QAPI Meetings
Penalty
Summary
Facility staff failed to ensure that the Infection Preventionist (IP) was in attendance at the Quality Assurance and Performance Improvement (QAPI) committee meetings as required. Record review of QAPI committee meeting sign-in sheets for the period from March 2025 through December 2025 showed that an IP had not attended the meetings on at least a quarterly basis, with 5 of 10 meetings reviewed lacking IP attendance. During an interview, the Corporate Clinical Resource Nurse, who was acting as the Quality Assurance coordinator and IP, stated that the facility had not had a staff member formally assigned as an IP for the past 10 months. This lack of an assigned IP and the resulting failure to have the IP present at QAPI meetings led to noncompliance with the requirement that the Quality Assessment and Assurance group include the required members and meet at least quarterly with appropriate representation.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect involving two residents. In the first case, a resident with Alzheimer's disease, depressive disorder, and a femur fracture alleged that a GNA was rough during care, causing bleeding. Although the resident initially refused assessment, a later skin check showed no injury. The facility's internal investigation included interviews with some staff and residents, but did not document whether staff were asked about prior observations of rough or unprofessional behavior by the GNA, nor whether other residents felt unsafe or had experienced similar issues. The investigation was concluded as unsubstantiated without fully determining if other residents were at risk. In the second case, following an allegation of neglect by another resident against a staff member, the facility suspended the alleged perpetrator and interviewed some residents on the staff member's assignment who could communicate. However, the investigation did not include head-to-toe assessments of non-verbal residents who had also been under the care of the alleged perpetrator. The DON acknowledged that these residents, who could not speak for themselves, were not assessed as part of the investigation, resulting in an incomplete review of the potential neglect incident.
Failure to Provide and Document Required ADL Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to residents who were unable to perform these tasks independently. In one case, a resident who was totally dependent on staff for incontinence care was found soiled by EMTs and ER staff after being unable to obtain help for over two hours, as documented in both emergency medical records and the resident's own report. Review of the resident's medical record and ADL documentation revealed multiple shifts with no recorded incontinence care provided, and the interim DON confirmed the lack of documentation for the identified periods. Another resident, diagnosed with dementia and severe cognitive impairment, was scheduled to receive two showers per week but received only one shower per month over a four-month period, as shown by a review of the ADL documentation. Discrepancies were found between the paper shower schedules and the electronic health record, and staff confirmed that showers were not properly scheduled in the EHR. A third resident, admitted for rehabilitation and nursing care after a serious fall and hospitalization, had multiple shifts with no documentation of personal care, including hygiene, eating, dressing, and toileting. The DON and NHA were unaware of the lack of documentation and could not provide evidence that care was given during these periods.
Failure to Maintain Accurate and Complete Medical Records for Oxygen Administration
Penalty
Summary
The facility failed to ensure that resident records were accurate and complete for a resident who was transferred to the hospital due to shortness of breath. Review of the clinical record showed that the resident experienced a change in condition and was given new orders for oxygen and other treatments by the on-call provider. Documentation from an LPN indicated that PRN oxygen at two liters per minute was administered. However, further review of the resident's medical record did not reveal any physician's order for the oxygen use. The Director of Nursing confirmed that no such order was entered into the resident's medical record.
Failure to Use Beard Restraints During Food Preparation
Penalty
Summary
Facility staff failed to adhere to professional standards for food safety by not wearing beard restraints during meal preparation and food handling in the kitchen. On two separate occasions, a dietary aide with a long beard was observed making pancakes and preparing resident meal trays without a beard restraint. Additionally, during a subsequent observation, both the corporate Certified Dietary Manager and the kitchen manager, who both had facial hair, were present in the kitchen without beard restraints. These staff members acknowledged not wearing the required protective equipment when questioned. The kitchen manager was informed of the deficiency but did not acknowledge it at the time, while the Nursing Home Administrator later acknowledged the findings during interviews. No information about residents' medical history or condition at the time of the deficiency is provided in the report.
Failure to Provide Accessible Survey Results
Penalty
Summary
The facility failed to ensure that the most recent federal survey results were readily accessible to residents, family members, and legal representatives. During an observation of the entrance hallway, a binder labeled as containing survey results did not include the most recent federal survey findings. The front desk receptionist was unaware of the missing documents until notified by surveyors and subsequently informed the administrator. Both the Regional Nurse Consultant and the Director of Nursing confirmed that the required federal survey tags were not present in the binder. It was also confirmed that the front desk was the only location in the facility where survey results were kept.
Failure to Provide Advance Directive Information to Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a cognitively intact resident with information and opportunities to formulate an advance directive. Upon review of the resident's medical record, there was no evidence of an advance directive or documentation that information or materials regarding advance directives had been offered. The Social Services Assessment and Documentation for the resident indicated that no conversation or materials related to advanced care planning were provided, and all relevant questions were answered in the negative. During interviews, the Social Services Director confirmed that the resident did not have an advance directive in place and that there was no documentation showing that information or opportunities to complete one had been provided. The resident was responsible for making their own medical decisions, and there was no durable power of attorney for healthcare on file. The lack of documentation and provision of information was acknowledged by the Social Services Director during the survey.
Failure to Protect Resident Property Due to Broken Cabinet Lock
Penalty
Summary
A resident reported that personal items, including body wash, shampoo, and $12.00 in cash, were stolen from their room. The resident stated that the lock on their bedside cabinet had been broken for approximately one to two months and that repeated notifications to nursing staff about the issue did not result in any action. During observations, the surveyor noted that the resident's bedside cabinet drawer was open, with a bank envelope containing money and a hearing aid visible and unsecured, and that the resident was unable to lock the drawer. On a subsequent observation, the drawer was again found ajar while the resident was not present in the room. The Director of Nursing acknowledged that the broken lock failed to protect the resident's property and that the resident could not file a grievance without staff assistance.
Failure to Identify Grievance Official and Resolve Resident Grievance
Penalty
Summary
The facility failed to properly identify a Grievance Official in its grievance policy, ensure the policy was followed for processing grievances, and make prompt efforts to resolve a resident's grievance. A resident reported missing hearing aids to staff, who acknowledged the complaint but did not initiate or follow the formal grievance process. The grievance policy reviewed by surveyors was incomplete, lacking the name and contact information of the Grievance Official. Staff interviews revealed confusion about the grievance process, with some staff unaware of their responsibilities or the steps required to resolve grievances. Grievance forms were not readily available at the nurses' station as expected, and there was no clear documentation or follow-up on the resident's complaint. A review of the grievance log showed that the resident had previously filed a grievance regarding the missing hearing aids, which was marked as resolved and signed by the Nursing Home Administrator. However, the resident continued to report the hearing aids as missing, and staff members, including the Social Services Department and unit manager, were unaware of the grievance or its resolution. The Nursing Home Administrator, who identified himself as the Grievance Official, was also unaware of the grievance filed months earlier and acknowledged that the process had failed the resident.
Failure to Document NPIs and Indications Prior to PRN Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication use, specifically regarding the administration of Ativan (Lorazepam) on an as-needed basis. Record review showed that the medication was administered 16 times in one month, but there was no documentation that non-pharmacological interventions (NPIs) were attempted or provided prior to giving the medication. Additionally, there was a lack of documentation indicating that the resident exhibited behaviors that would justify the use of the psychotropic medication on several occasions. Interviews with the Nurse Manager revealed that nursing staff are expected to document both the behaviors leading to the administration of psychotropic medications and the NPIs attempted beforehand. Multiple avenues for such documentation were available, including the eMAR, medication orders, progress notes, and behavior monitoring tasks. Despite these expectations and available methods, the required documentation was not present in the resident's medical record for the identified dates.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hagerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western Md Hospital Center | 2.9 mi | ★★★★★ | 20 | 0 |
| Coffman Nursing Home | 3.2 mi | ★★★★★ | 0 | 0 |
| Hagerstown Healthcare Center | 4.6 mi | ★★★★★ | 31 | 0 |
| Julia Manor Nursing And Rehabilitation Center | 5 mi | ★★★★★ | 6 | 0 |
| Creekside Center For Rehabilitation And Nursing | 6.1 mi | ★★★★★ | 34 | 1 |
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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.