Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Heritage Llc during CMS and state inspections, most recent first.
Staff failed to accurately code multiple MDS assessments, leading to missing and incorrect entries for medications, falls, behaviors, and treatments. Anticonvulsant and antianxiety medications documented on MARs were not captured in the high-risk drug classes section for several residents, while one resident was incorrectly coded as receiving hypoglycemic medication despite no such orders. A resident’s documented fall was not coded in the falls section, and another resident’s oxygen therapy was omitted from the special treatments section while hospice services and limited life expectancy were incorrectly coded without supporting documentation. In addition, a resident with clearly documented aggressive and combative behaviors was coded as having no physical or verbal behavioral symptoms on the MDS.
A resident who was alert and oriented reported that a nurse repeatedly entered the room despite the resident’s request to keep the door closed and to stop coming in. A GNA accompanied the resident back to the room and informed an LPN of the resident’s wishes, but the LPN stated he did not care and entered anyway to give meds to the roommate. The resident continued to ask the LPN to leave, the situation escalated into yelling, and both the resident and the LPN used expletive language. The LPN told the resident to hit him, stated the resident would not do anything, and threatened to beat the resident, which was witnessed and later confirmed as verbal abuse by supervisory staff and the administrator.
A resident who was alert, oriented, and able to express needs had standing orders for showers on specific days but, over a two‑month period, received only bed baths instead of the ordered showers. The resident and the responsible party both reported that no showers had been provided during this time, and facility documentation confirmed only bed baths with one documented refusal related to diarrhea. The resident was agreeable to occasional bed baths but expected to be offered showers on scheduled shower days, which did not occur.
A resident with acute prostatitis did not receive IV antibiotics as ordered by the physician. Hospital discharge instructions included daily Ertapenem through the end of the month, but the final scheduled dose was not administered according to the MAR. The antibiotic regimen was later changed to Meropenem every 8 hours, and a scheduled evening dose was also not documented as given. The DON confirmed that staff failed to administer these ordered antibiotic doses.
Two residents did not receive respiratory care in accordance with professional standards. One resident with obstructive sleep apnea had a hospital discharge summary directing continuation of BiPAP for sleep, but BiPAP was neither ordered nor documented as administered for the first three nights after admission. Another resident with COPD, asthma, chronic myeloid leukemia, and a history of acute on chronic hypoxic hypercapnic respiratory failure had intermittent oxygen use documented in vital signs, yet there were no physician orders for oxygen therapy, tubing changes, humidification, O2 saturation goals, or basic oxygen care, despite facility policy requiring a provider order specifying liter flow and delivery device; the DON confirmed the absence of related documentation on the MAR and TAR.
Dirty and Damaged Environmental Conditions: A surveyor observed a busted bathroom ceiling around a sprinkler, dusty and rust-stained hallway vents, and a dirty laundry-room eye-wash sink that was leaking and had towels underneath to catch the water. The maintenance director said vents were not on a scheduled cleaning routine and acknowledged the ceiling and vents needed attention; the housekeeping supervisor said the sink issue had been reported earlier and had only been fixed temporarily.
A facility failed to label O2 tubing with change dates for all residents reviewed on O2 therapy. Surveyors observed nasal cannulas connected to humidifiers without labels, and staff were unsure when tubing had last been changed or how often it was changed. Some residents had orders for continuous O2, and two had orders for weekly tubing changes with date-and-initial labeling, but the tubing was still unlabeled.
Failure to Verify GNA Competencies Upon Hire: Review of employee files found that four of five randomly selected GNA records did not show competency verification upon hire. An educator confirmed that GNA skills must be verified before working on a unit and acknowledged that the competencies for these GNAs had not been verified. The DON was informed of the findings.
Laundry staff were observed sorting dirty linens without the required PPE, as a laundry aide wore gloves and a mask pulled below the nose but no protective gown while handling soiled linens. On the clean side, personal items and drinks were left on the clean folding tables, including coffee, an energy drink, lunch bags, a cell phone, candy, and shampoo/body wash. The laundry supervisor confirmed staff should wear gowns, gloves, and masks for dirty linen sorting.
Failed pest control program with gnats observed in the conference room throughout the survey and in a resident’s room, where a brown insect and gnat were seen flying around the resident. The resident tried to swat them and said flies were a problem. The Maintenance Director stated the facility used a weekly pest vendor, had prior mice issues, and that the vendor did not address gnats because they were considered a water and cleanliness issue.
Facility staff did not provide necessary personal hygiene and bathing assistance to two totally dependent residents. One resident was found with neglected toenail care, and another had no documented showers or bed baths for several months, despite being fully dependent due to significant physical limitations. Documentation and staff interviews confirmed the lack of provided care and incomplete records.
Two residents experienced significant delays in receiving prescribed medications and wound care treatments. One resident's medications were repeatedly administered several hours late, primarily due to short staffing and reliance on agency staff, as confirmed by MAR review and staff interviews. Another resident did not receive wound care or IV antibiotics until days after admission, with no documentation of earlier treatment. Facility leadership acknowledged the lack of timely care and absence of supporting documentation.
A resident who was alert and oriented experienced severe, unrelieved pain for several hours without timely assessment or administration of pain medication. Although pain medications were reportedly ordered and administered, there was no documentation in the MAR to support this, and no pain assessment was recorded. Staff interviews confirmed that pain management and documentation protocols were not followed, resulting in a significant delay in addressing the resident's pain before hospital transfer.
Facility staff failed to obtain two required physician certifications of incapacity and complete Advance Directives for a resident admitted with altered mental status and confusion. The record showed only one physician had signed the certification related to medical condition, substitute decision making, and treatment limitation, and staff confirmed the second signature was missing.
Failure to Immediately Report Allegation of Abuse: A facility failed to immediately report an allegation of verbal abuse involving a resident and did not timely notify the OHCQ. The GSD became aware of the concern and did not notify the NHA until 2 days later, and the initial report to the State Survey Agency was also delayed. The NHA stated staff are expected to report abuse allegations immediately to a supervisor, who would then notify the DON or NHA and begin an investigation.
MDS assessments were not kept accurate for 3 residents whose matrix entries still listed COVID as an active dx. The Infection Preventionist stated there were no residents with COVID in the facility, but review of the MDS showed COVID remained in the active dx section for each resident, and the MDS Coordinator was unaware the dx was still listed.
Failure to hold quarterly care plan meetings was identified for 2 residents. One resident’s RP reported receiving only a recent invitation and no prior care plan meeting notice, and the record showed no evidence of a completed meeting beyond one attendance sheet and a later invitation. Another resident said no care plan meeting had been held or offered, and the record showed the meeting occurred late with no documentation of advance notice; the SW confirmed the delay and lack of proof of invitation.
A resident with chronic back and shoulder pain had scheduled OxyContin doses documented late on multiple occasions, with the MAR showing a repeated pattern of staff signing medications after administration rather than immediately after each dose. The resident also reported that pain meds were sometimes reordered only when nearly gone, causing delays while waiting for them to arrive. The DON acknowledged the facility did not consistently reorder as expected, and an RN stated he would sign medications before giving them and save the documentation after finishing all meds.
A resident with paraplegia and an above-knee amputation repeatedly requested an exercise band and reported never being placed in a wheelchair, but Rehab and nursing staff did not provide the requested support or document a clear reason for the restriction. The DOR said the resident was only screened, not fully evaluated, and the record lacked documentation that Wound Team staff said the resident could not get out of bed or into a wheelchair. Therapy screening noted multiple indicators for therapy needs, yet no PT order was in place on readmission until after surveyor intervention, and staff interviews confirmed the resident had not been seen in a wheelchair.
Failure to complete fall assessments after resident falls. A resident with a hospital transfer after a fall, another resident with multiple falls, and a third resident with repeated falls all lacked post-fall assessments in the record. The DON confirmed the assessments should have been completed after the falls and acknowledged the inconsistency.
Failure to Address Significant Resident Weight Loss: A resident experienced repeated significant weight loss, including a 12.4% loss in 15 days and additional losses over subsequent weeks. Although the dietitian completed nutrition assessments and notes, there was no documentation of an assessment, family or provider notification, revised care plan, or other interventions to address the weight loss, and the DON validated the missing documentation.
Undated insulin and nebulizer medications, along with expired OTC drugs, were found in medication carts during observation. An agency nurse and another nurse acknowledged that opened insulin pens and nebulizer solutions should have been dated, and the Unit Manager stated insulin in the cart must be dated and refrigerated until opened while expired OTC medications should be removed.
A facility failed to keep MARs complete and accurate for three residents. One resident had missing MAR entries for oxycodone despite narcotic sign-out documentation, another had sliding-scale insulin doses recorded incorrectly as an equal sign instead of the actual amount given, and a third had no MAR documentation for Narcan that was ordered and administered after the resident became unresponsive.
Failure to offer pneumococcal vaccine: A resident’s immunization record did not show that the pneumococcal vaccine was offered, refused, or that education was provided. The IP stated the vaccine is offered on admission but confirmed it had not been offered initially to the resident, and later obtained consent after speaking with the resident. The DON was made aware of the concern.
The facility failed to offer COVID-19 immunization as required or appropriate for two residents reviewed for immunizations. Record review showed no documentation that the vaccine was offered, refused, or that education was provided, and the IP later stated the vaccine had not been offered initially on admission. Two later consent forms showed one resident consented and the other refused after being offered the vaccine.
Incomplete Nurse Aide Training Records: The facility failed to track nurse aide participation in required annual training, including abuse prevention and dementia management. Review of employee files found one GNA with incomplete abuse and neglect prevention training documentation and another GNA with no evidence of required annual training for the prior year. An educator confirmed the missing training records during interview.
Failure to Post Required Nurse Staffing Information: The facility did not post the required nurse staffing information in a public area. During the annual survey, the survey team observed that the staffing post was missing. The DON later confirmed that the facility had unit assignments, but did not post the facility name, date, resident census, or the total number and actual hours worked by nursing staff.
A nurse, unfamiliar with the facility and distracted during medication pass, administered Methadone to a resident instead of the prescribed Methylphenidate by failing to verify the medication name, dose, and form. The nurse did not follow the five rights of medication administration, and the error was only discovered after the medication was given. The resident was later found unresponsive and the incident was reported to the Medical Examiner.
Inaccurate MDS Coding for Medications, Falls, Behaviors, and Treatments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, resulting in omissions and inaccuracies in several MDS sections. For one resident receiving Gabapentin every eight hours for neuropathy, the anticonvulsant was not captured in Section N0415 (High-Risk Drug Classes) on two separate MDS assessments. Another resident experienced a documented fall, noted in the medical record as being found on the floor in a sitting position, but this fall was not coded in Section J1800 (any falls since admission/entry or prior assessment). A third resident had hypoglycemic medication use coded in Section N0415, despite the November MAR showing no hypoglycemic medications administered during that period. Additional inaccuracies were identified for a resident who received Lorazepam, an antianxiety medication, which was not captured in Section N0415 on a discharge MDS, and whose use of oxygen via nasal cannula was not coded in Section O (Special Treatments, Procedures, and Programs). The same resident was incorrectly coded in Section O as receiving hospice services and in Section J1400 as having a condition with a life expectancy of less than six months, despite no documentation supporting hospice services or such a prognosis. Another resident with documented aggressive and combative behavior, including agitation, psychosis, throwing objects at staff, and destroying property, was coded as having no physical or verbal behavioral symptoms in Section E0200. This resident was also receiving Gabapentin three times per day per the MAR, but the anticonvulsant was not captured in Section N0415. The MDS Coordinator confirmed these errors and noted that other staff had been filling in on MDS assessments during the primary coordinator’s leave.
Failure to Protect Resident From Verbal Abuse by Nursing Staff
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse by a staff member. An alert and oriented resident, admitted in 2025, approached the nursing station and reported that a nurse kept entering the resident’s room despite the resident’s request to keep the door closed and to stop coming into the room. A geriatric nursing assistant accompanied the resident back to the room and informed the nurse of the resident’s request. The nurse stated he did not care and entered the room anyway, stating he needed to administer medications to the roommate. The resident repeatedly told the nurse to leave the room, but the nurse refused, leading the resident to begin yelling. The geriatric nursing assistant reported that the situation became heated, with the nurse and the resident speaking to each other “like they were on the streets” and both using expletive language. The nurse told the resident to hit him and stated that the resident was not going to do anything, and that he would “beat the [expletive]” out of the resident. The nursing supervisor, after being notified by the geriatric nursing assistant, went to the scene and personally heard the nurse threaten to beat the resident. The supervisor stated that the nurse was being abusive and that he was afraid the situation was going to become physical. The facility’s administrator later confirmed that the facility substantiated verbal abuse of the resident by the nurse.
Failure to Provide Ordered Showers and Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to provide showers as ordered for a resident who required assistance with activities of daily living (ADLs). The resident had physician orders to receive showers on Tuesdays and Fridays during January and February 2026, but interviews and record review showed that these ordered showers were not provided. On 2/20/26, the resident’s responsible party reported that the resident had not received a shower in the prior two months, and the resident, who was alert, oriented, and able to express needs, confirmed not having had a shower during that period and expressed a desire for one. Documentation in the treatment and GNA records showed that the resident had only received bed baths, with one documented refusal of a shower/bed bath on a single occasion due to diarrhea, and there was no documentation that showers were offered on the scheduled shower days as ordered. The resident stated they were not opposed to receiving a bed bath occasionally but expected to be offered a shower on designated shower days rather than being given only bed baths. The surveyor’s review of records corroborated that showers were not provided in accordance with the care plan and orders for the months reviewed, and that the resident’s preference for showers on scheduled days was not honored, except for the one documented refusal related to diarrhea.
Failure to Administer Ordered IV Antibiotics as Prescribed
Penalty
Summary
Facility staff failed to administer ordered IV antibiotics as prescribed for a resident with acute prostatitis. The resident was admitted in December 2025 with a diagnosis including acute prostatitis, and the hospital discharge summary ordered Ertapenem 1 gm IV daily through 1/30/26. Review of the January 2026 Medication Administration Record showed the resident did not receive the ordered Ertapenem dose on 1/30/26. The resident’s antibiotic regimen was later changed by the physician to Meropenem 2 gm IV every 8 hours on 2/4/26. Review of the February 2026 Medication Administration Record revealed no evidence that the resident received the scheduled Meropenem dose on 2/15/26 at 10:00 PM. In an interview on 2/25/26 at 8:30 AM, the Director of Nursing confirmed that facility staff failed to administer the ordered antibiotic medications on both 1/30/26 and 2/15/26.
Failure to Provide Ordered BiPAP and Properly Order/Document Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with professional standards of practice for two residents who required such care. One resident was admitted with a diagnosis that included obstructive sleep apnea and had a hospital discharge summary directing continuation of BiPAP for sleep. Review of the resident’s December Treatment Administration Record showed that the BiPAP was not ordered or documented as administered until three days after admission, resulting in three nights without the prescribed BiPAP therapy. In an interview, the Administrator confirmed that facility staff did not administer the resident’s BiPAP during those three nights following admission. For another resident, admitted with COPD, asthma, and chronic myeloid leukemia, the medical record documented use of oxygen at 3 LPM via nasal cannula and a history and physical noting acute on chronic hypoxic hypercapnic respiratory failure, COPD, asthma, and home oxygen use of 2–3 liters, as well as recent community-acquired pneumonia and acute hypoxic respiratory failure while hospitalized prior to admission. The vital sign section of the electronic medical record showed intermittent use of oxygen; however, review of the December and January physician’s orders revealed no orders for oxygen therapy, tubing changes, humidification, oxygen saturation goals, or basic care related to oxygen therapy. The facility’s oxygen therapy policy required verification of a medical doctor order including liter flow and type of O2 delivery device. During an interview, the DON confirmed that the MAR and TAR contained no documentation of oxygen usage, tubing changes, or humidification for this resident.
Dirty and Damaged Environmental Conditions
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment on one nursing unit and in the laundry room. During initial rounding, a surveyor observed that the bathroom ceiling in one resident room was busted inward around the sprinkler area, measuring about 10 by 4 inches. On the second-floor hallway near the medication room and janitor's closet, three vents were observed with dust buildup and multiple rusty brown stains. The maintenance director stated that vents were not on a scheduled cleaning routine and acknowledged that the hallway vents needed to be vacuumed, cleaned, or replaced, and that the bathroom ceiling also needed repair. In the laundry room, the dirty side where soiled laundry was received and sorted had a large eye-wash sink that was very dirty and covered with brown stains. The sink was also leaking, with towels placed underneath to catch the water. The housekeeping supervisor/account manager stated that the maintenance director had been informed about the sink about 2 weeks earlier, that it had been fixed temporarily, and that it stopped working again. The DON was later made aware of the concern.
Oxygen Tubing Not Labeled With Change Dates
Penalty
Summary
The facility failed to label oxygen tubing with change dates for 7 of 7 residents reviewed for respiratory care. During initial rounding, residents on oxygen therapy were observed with nasal cannulas connected to humidifiers at the bedside, but the tubing was not labeled to show when it had last been changed. One resident stated that the oxygen tubing was only changed when asked. Record review for several residents showed oxygen orders, including continuous oxygen at 2 L/min or 3 L/min via nasal cannula, and for two residents the orders specifically included weekly tubing changes with labeling of each component with date and initials, yet the tubing was not labeled. Staff interviews showed uncertainty about the tubing change process and documentation. A registered nurse stated that day shift changed the tubing but did not know the frequency or when it was last changed, and initially did not know whether the tubing should be labeled. The unit manager stated that oxygen tubing should be changed every 7 days and should be labeled, and the nurse educator stated that staff were getting inservice on oxygen delivery and labeling of tubing and equipment. Surveyors also observed additional residents on oxygen whose tubing lacked labels, and one resident was unsure when the tubing had last been changed.
Failure to Verify GNA Competencies Upon Hire
Penalty
Summary
Nurses and nurse aides were not ensured to have the appropriate competencies to care for residents because the facility failed to implement a system to verify newly hired Geriatric Nursing Assistants' skill sets. During review of five randomly selected GNA employee files, four files did not contain records showing that competencies were verified upon hire for GNA #15, GNA #17, GNA #36, and GNA #37. The files showed these employees were hired in March 2023, December 2022, September 2023, and July 2024, respectively. During interview, the educator confirmed that GNA skills are required to be verified before they begin working on a unit and acknowledged that the competencies and skills for these four GNAs had not been verified upon hire. The DON was informed of these findings during interview.
Laundry PPE and Clean Table Contamination
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because linen was not processed in a manner that prevented infection. During observation of the laundry room, two folding tables were seen on the clean side, and the clean folding tables had multiple personal and food items on them, including an ice coffee cup, a charging cell phone, lunch bags, a table fan with dust on the blades, an open energy drink, shampoo and body wash, and an open candy packet. Staff #31 acknowledged that the items were not supposed to be left on the clean laundry folding table and removed them after being questioned. On the dirty side of the laundry room, Staff #32 was observed sorting dirty linens while wearing a glove and a mask that was pulled down below the nose, and she was not wearing a protective gown. Although yellow gowns and gloves were available nearby, Staff #31 stated that staff were supposed to wear gowns and gloves for sorting dirty linens, and later stated she had been taught to wear gloves and a mask but not gowns. The laundry supervisor later confirmed that staff should be wearing gowns, gloves, and masks for sorting dirty linens and stated the staff had been trained to use PPEs. The DON was made aware of the concerns.
Failed Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. Surveyors observed multiple flying gnats in the conference room on the first day of the survey, and throughout the survey period gnats were observed each day in that room. During initial rounds, a brown insect and a gnat were observed flying around a resident in Room 125, and the resident tried to swat them and stated that flies are a problem. In an interview, the Maintenance Director stated the facility had an insect/pest maintenance program through Allstate that came weekly, that the facility had experienced mice more so last winter and had implemented a plan of correction involving removal of PTAC covers and placement of hardware cloth on the external units, and that the seasonal gnats were not addressed by the vendor because they were considered a water and cleanliness issue.
Failure to Provide Personal Hygiene and Bathing Assistance to Dependent Residents
Penalty
Summary
Facility staff failed to provide necessary personal hygiene services to residents who were totally dependent on staff for activities of daily living (ADL). In one instance, a resident was observed to have long, yellowed, thickened, and misshapen toenails, with one toenail having fallen off. The resident’s Minimum Data Set (MDS) indicated total dependence on staff for personal hygiene. Interviews with staff revealed that toenail care was the responsibility of nurses or podiatry, but the resident had not been seen by podiatry until after the surveyor’s intervention, indicating a lack of timely care. Another resident, who was dependent for all ADLs due to diagnoses including muscular dystrophy and Friedreich ataxia, was reported by a family member to have not received a shower in years and to have a layer of filth on their head. Review of the resident’s medical record and facility documentation showed no evidence of showers or bed baths being provided over several months. The facility’s documentation systems, including Point of Care (POC) and paper shower sheets, lacked records of bathing or showering for this resident, except for two instances where refusal was documented. Staff interviews confirmed that showers were scheduled and assigned, but documentation was incomplete or missing. Both residents had care plans indicating total dependence on staff for personal hygiene and bathing, with goals for their ADL needs to be met. However, the lack of documented care and observations of poor hygiene demonstrated that the facility did not provide the required assistance with personal hygiene and bathing for these dependent residents.
Delayed Medication and Wound Care Administration
Penalty
Summary
The facility failed to provide timely medication administration and wound care treatment to two residents, as identified during a recertification and complaint survey. For one resident, multiple medications were administered 2-4 hours late on various days throughout the month, as confirmed by a review of the Medication Administration Records (MAR). The resident attributed the delays to agency staff frequently used by the facility, and a registered nurse confirmed that short staffing and lack of medication aides were common reasons for late medication passes. The Director of Nursing acknowledged awareness of the issue and stated that medication times had been adjusted in an attempt to address the problem, but late administration persisted. Another resident experienced a delay in wound care and IV antibiotic administration following admission. The wound treatment order was not placed until two days after admission, and there was no documentation of wound care prior to that order. Additionally, the resident's IV antibiotic, vancomycin, was ordered a day after admission, with the first dose administered later that day, and no evidence of earlier administration. Both the Director of Nursing and the Nursing Home Administrator confirmed there were no additional orders or documentation to support earlier treatment or medication administration.
Failure to Provide Timely Pain Management and Documentation
Penalty
Summary
A deficiency was identified when a resident experienced severe, unrelieved pain for an extended period without timely assessment or intervention. The resident, who was alert and oriented with a BIMS score of 15/15, began experiencing severe bilateral leg pain, rated at 10/10, starting in the evening and continuing into the following morning. Despite the resident's ongoing complaints and visible distress, there was no documented pain assessment or administration of pain medication during this time. Progress notes later indicated that pain medications and a lidocaine patch were ordered and reportedly administered, but the Medication Administration Record (MAR) did not reflect any such administration on the date in question. Staff interviews revealed that pain assessments are expected to be conducted every shift, and the DON confirmed that pain should be managed immediately with all interventions documented in the MAR. However, there was a five-hour gap between the initial documentation of severe pain and the resident's transfer to the hospital, during which no pain assessment or medication administration was documented. This failure to provide timely pain management and proper documentation constituted the identified deficiency.
Missing Second Physician Certification for Advance Directives
Penalty
Summary
Facility staff failed to ensure that two physicians' certificates of incapacity were obtained and that Advance Directives were completed in accordance with the Health Care Decisions Act for one resident reviewed during the recertification/complaint survey. The resident was admitted in August 2025 with an altered mental status, and the medical record showed a physician certification related to medical condition, substitute decision making, and treatment limitation completed on 8/14/25 by one physician who documented that the resident was unable to make decisions due to a state of confusion. However, the second physician's signature was missing. During interviews, the Social Worker confirmed that two signed certifications are required when residents are incapable and that the forms should be completed within a week, and the review with another staff member confirmed that only one form had been completed.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to immediately report an allegation of suspected resident abuse and failed to timely report the allegation to the State Survey Agency, the Office of Health Care Quality (OHCQ). This deficiency involved 1 resident reviewed during the recertification/complaint survey. The report states that a facility incident involving Resident #42 was reviewed, and the facility’s records showed that the Guest Services Director (GSD) became aware of an allegation of verbal abuse on 12/11/24 at 8:59 AM. According to the facility’s initial report, the Nursing Home Administrator (NHA) was not notified by the GSD until 12/13/24 at 10:00 AM. The facility then reported the allegation to the OHCQ at 11:50 AM on 12/13/24 and began an investigation, which was 2 days after the GSD became aware of the concern. During interview, the NHA stated that staff who become aware of an allegation of abuse are expected to report it immediately to their supervisor, who would then immediately report it to the DON or NHA and start an investigation. The NHA acknowledged and confirmed understanding when the surveyor reviewed the delay in notification and reporting.
MDS Diagnoses Not Updated on Facility Matrix
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments reflected accurate active diagnoses for 3 residents identified on the facility matrix with COVID. During the infection control investigation, the matrix showed COVID as an active diagnosis for Residents #82, #113, and #13, while the Infection Preventionist stated there were no residents with COVID in the facility. Review of the MDS assessments for these residents showed that the Active Diagnoses section still included U07.1 COVID-19. The MDS Coordinator stated he/she was not aware of the COVID diagnosis for the 3 residents and needed to look into it. Further review showed Resident #82 had been admitted with COVID and the diagnosis remained in the MDS diagnosis tab when the matrix was pulled; Resident #113 had tested positive for COVID and the quarterly MDS still listed COVID when the matrix was pulled before completion of a later quarterly assessment; and Resident #13 had tested positive for COVID, with COVID remaining in the diagnosis tab and appearing on multiple MDS assessments, including a significant change assessment, when the matrix was pulled.
Failure to Hold Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to hold care plan meetings at least quarterly for 2 of 4 residents reviewed for care plans during the recertification/complaint survey. Resident #13’s responsible party stated that a recent invitation to a care plan meeting on 9/17/25 was the first invitation received and reported no prior invitation or attendance at a care plan meeting. Review of the resident’s medical record did not reveal evidence that a care plan meeting had been held, and the Social Worker later provided only an attendance sheet from a 3/28/25 care plan meeting and an invitation for the upcoming 9/17/25 meeting, stating that no additional documentation could be found and that the meeting may have been missed or overlooked. Resident #2 stated during interview that after being in the facility for 7 months, the resident had not had a care plan meeting and had never been invited. The social work progress notes showed a care plan meeting on 6/26/25, but the resident had been admitted earlier in 2025 and should have had a quarterly care plan meeting in May 2025. Further review did not show advance notice for the meeting. The Social Worker confirmed the meeting was held late because she was the only social worker at the time and later stated she did not have documentation showing that an invitation to the June care plan meeting had been provided to the resident.
Late Documentation of Scheduled Pain Medication
Penalty
Summary
Facility nursing staff failed to follow professional standards of nursing practice when documenting medications given to a resident with chronic back and shoulder pain. Review of the Medication Administration Audit Report for August and September 2025 showed an order for OxyContin 20 mg twice daily, with a scheduled administration time of 9:00 AM and 9:00 PM. The medication was documented as given late on multiple dates, including several morning doses recorded hours after the scheduled time and several evening doses recorded after the scheduled time, with this pattern occurring on 18 out of 44 days reviewed. Resident #102 stated that pain medications were sometimes not reordered until they were almost gone, causing the resident to receive the medication late while waiting for it to come in. The resident’s care plan addressed chronic back/shoulder pain and included administering pain medication per order and anticipating the resident’s need for pain relief. The DON stated that the normal process was to reorder medication when it reached the last column of the blister pack, but acknowledged that staff did not consistently do this. RN #22, identified as one of the staff documenting medications late, stated that medications were signed for before administration and then saved after all medications were given, and acknowledged that the medication was given on time but not documented on time.
Failure to Maintain Resident Mobility and Provide Rehab Services
Penalty
Summary
The facility failed to provide care and services to maintain or improve a resident’s ability to perform ADLs and mobility-related functions. Resident #6, who was admitted with paraplegia and an acquired absence of the right leg above the knee, stated s/he repeatedly requested an exercise band to strengthen the upper body and help with self-mobility in bed, but was told by nursing and Rehab staff that Rehab would have to decide and was not provided one. The resident also stated s/he had never been placed in the wheelchair since admission and was told by staff that Rehab said s/he could not get up because of pressure ulcers. The record review showed the resident had a care plan addressing limited physical mobility and included interventions for exercise, mobility assistance, and PT/OT referrals as ordered. However, the DOR stated the resident was only initially evaluated on admission and then screened quarterly, while also stating there was no documentation that the Wound Team told Rehab the resident could not get into the wheelchair. The medical record did not contain documentation from the Wound Team supporting a restriction from wheelchair use, and the wound provider notes reviewed did not state the resident could not get out of bed at all or could not get into the wheelchair. The therapy documentation reviewed showed a 9/12/24 Therapy Screen Form that concluded no therapy was indicated, despite screening indicators including wounds, decreased ROM, decline in bed mobility/transfers, decline in ADLs, and appropriateness for an exercise program. The DON stated the facility’s process was to place PT orders for admissions/readmissions and to let therapy evaluate requests for adaptive equipment, but there was no PT order when the resident returned from the hospital on 9/1/25 until after surveyor intervention. Staff interviews also showed RN #2 and RN #12 had never assisted the resident to the wheelchair and had not seen the resident in the wheelchair during their time at the facility, and the DON could not find documentation that the resident refused to get out of bed.
Failure to Complete Fall Assessments After Resident Falls
Penalty
Summary
The facility failed to complete adequate fall risk assessments for residents who had repeated falls. Resident #15 reported a fall that resulted in a hospital transfer, and the medical record showed the resident was found on the floor beside the bed with hip pain and was sent to the hospital, where imaging revealed a partial dislocation of the left arm and a compression fracture in the spine. Although a fall assessment had been completed earlier that same day and classified the resident as low risk with a score of 3, no additional assessment was completed after the fall. The DON reviewed the record with the surveyor and confirmed that a fall assessment was not completed after the incident. Resident #16 reported having many falls, and the medical record showed an unwitnessed fall with no fall assessment completed afterward. Resident #94 also had multiple falls documented, including one event where the resident sat on the floor and was assisted back to bed, and another fall that resulted in transfer to the hospital with a suspected injury. No fall assessments were documented after either fall, and the DON could not locate any assessments completed after those incidents. The DON confirmed that fall assessments should be completed after a fall and stated that fall assessment completion was not consistent.
Failure to Address Significant Resident Weight Loss
Penalty
Summary
The facility failed to address a significant weight loss for one resident who experienced multiple documented declines in body weight while remaining in the facility. The resident reported weight loss during an interview, and the medical record showed a loss of 15.8 lbs. (12.4%) in 15 days, followed later by additional losses of 5.2 lbs. (4.9%) in 5 days and 4 lbs. (4%) in 7 days. Nutrition assessments were completed several times by the dietitian, and nutrition notes were written on two occasions, but there was no documentation addressing the resident’s significant weight loss. During interview, the dietitian stated that nutrition assessments were required on admission, every 90 days, and when weight loss was identified, and that weekly weight loss meetings were held with the clinical team. When asked about the resident’s significant weight loss, the dietitian confirmed that the loss was significant and stated there was no documentation to support any interventions. The DON later reviewed the record and validated that there was no documentation of an assessment, notification to the family member and provider, a revised care plan, or additional interventions to address the resident’s significant weight loss.
Undated Insulin, Nebulizer Medications, and Expired OTC Drugs in Medication Carts
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in accordance with accepted professional principles. During observation of the 2nd floor East Hall medication cart, an unsealed Lantus 100 unit/ml vial labeled for Resident #192 was found without the date it was opened, an opened box of Ipratropium/Solution Albuterol labeled for Resident #95 was not dated, an unsealed Insulin Lispro pen 100 U/ml labeled for Resident #192 was not dated, an unsealed Insulin Lispro pen labeled for Resident #193 was not dated, and an opened box of Albuterol 2.5mg/3ml solution labeled for Resident #138 was not dated. Staff #35 stated the unsealed insulins should have a date on them and the opened nebulizer solution boxes should have a date on the foil pack and box when opened. During observation of the 2nd floor North Hall medication cart, an unsealed Insulin Lispro pen 100 U/ml labeled for Resident #192 was found without the date it was opened, along with a 100-tablet bottle of Oyster Shell Calcium 250mg + Vit. D expiring 07/2025 and a 300-tablet bottle of Calcium 600mg + D3 expiring 04/2025. Staff #30 stated the insulin pen should have been dated and the expired OTC medications should have been removed from the cart. Staff #28, the Unit Manager, stated insulin kept in the medication cart must be dated and refrigerated until opened, OTC medications that have expired should be removed from the cart, and nebulizer medications must be dated once opened.
Incomplete and inaccurate medication documentation in resident records
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for three residents. For one resident, a review of a complaint involving a possible overdose showed Oxycodone HCL 10 mg was ordered, discontinued, reordered, and then placed on hold, and the narcotic count sheet documented multiple sign-outs of the medication on several dates and times. However, the resident’s MAR had blank spaces for those same dates and times, and staff stated that narcotics should be documented on the MAR when administered. The DON agreed that medications must be documented on the MAR when given. For another resident, the physician ordered insulin lispro to be administered by sliding scale based on blood sugar levels, but the September MAR did not record the amount of insulin administered when blood sugars were high enough to require it. The DON and unit manager stated the order had been entered incorrectly in the computer system so that an equal sign appeared instead of the actual dosage administered. For a third resident, a facility incident report described the resident becoming unresponsive, then combative, then unresponsive again, with Narcan ordered and administered by the physician, but the January MAR did not show that Narcan had been transcribed or administered. The DON could not find the order or MAR documentation, and the record lacked the medication information that would have been available for review.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer the pneumococcal vaccine as appropriate for residents, as shown by the record review of Resident #2 during the recertification/complaint survey. The resident’s immunization record did not show that a pneumococcal vaccine, which protects against pneumonia, was offered, nor did it show that the resident refused the vaccine and was educated about it. When the Infection Preventionist was asked whether the facility offers the pneumococcal vaccine to residents, she stated that it is offered on admission, but she needed to check whether Resident #2 had been offered it. She later provided an informed consent form dated 9/15/25 and stated that the vaccine had not been offered initially on admission and that she had just spoken with Resident #2, who consented to receive the pneumonia vaccine.
Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to offer COVID-19 immunization as required or appropriate for residents, affecting 2 of 5 residents reviewed for immunizations during the recertification/complaint survey. Record review for two residents showed no documentation that a COVID-19 vaccine was offered, and there was no documentation that either resident refused or received education about the vaccine. When the Infection Preventionist was asked whether both residents had been offered the COVID-19 immunization on admission, she said she would check and get back to the surveyor. Later, two vaccine consent forms dated after the survey review were provided, showing that one resident consented to vaccination and the other refused and was educated; the Infection Preventionist stated the vaccine had not been offered initially on admission to both residents.
Incomplete Nurse Aide Training Records
Penalty
Summary
The facility failed to demonstrate a process to track nurse aide participation in required training to ensure all nurse aides received 12 hours of annual training that included abuse prevention and dementia management, and to address areas of weakness identified in nurse aide performance reviews. During review of five randomly selected Geriatric Nursing Assistant employee files, one employee hired in July 2024 had incomplete abuse and neglect prevention training records because the second page of the training was not completed, and another employee hired in December 2022 had no evidence of the required training for 2023. In interview, the educator stated that the facility uses an online training program that she monitors, and she confirmed after reviewing the files that one GNA had not completed the abuse prevention training and the other had no record of the required annual training.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the required nurse staffing information on a daily basis. During the annual survey on 9/08/25 at 7:30 AM, the survey team entered the facility and observed that the required staffing information was not posted in a public area. During an interview on 9/15/25 at 8:15 AM, the DON stated that the facility has assignments for each unit, but they do not post the staffing information, including the facility name, date, resident census, and the total number and actual hours worked by nursing staff, in a public area. The surveyor shared this concern, and the DON validated it.
Significant Medication Error: Methadone Administered Instead of Methylphenidate
Penalty
Summary
A significant medication error occurred when a registered nurse (RN), who was working their first shift at the facility as an agency nurse, administered Methadone to a resident instead of the prescribed Methylphenidate. The resident had been admitted with diagnoses including narcolepsy, muscle weakness, and recurrent falls, and was scheduled for discharge. The error happened when the RN, while administering medications, saw the letters 'M-E-T-H' on the medication administration record and assumed the medication was Methadone, without verifying the medication name, dosage, or form. The RN did not compare the medication pulled from the cart to the resident's medication administration record, did not confirm the medication, and did not check if the medication was in the correct form, resulting in the administration of a liquid Methadone dose instead of the prescribed tablet form of Methylphenidate. After realizing the error about an hour later, the RN assessed the resident, found them to be sleepy but with stable vital signs, and reported the incident to the nursing supervisor. The supervisor instructed the RN on documentation, contacting the on-call physician, and notifying the resident's family. The on-call provider was informed but was unable to obtain critical information from the RN, such as the resident's name, date of birth, and the exact dose of Methadone administered. The provider was told that the Methadone had been intended for another resident who was not currently admitted, and the RN could not locate the empty bottle or confirm the dose given. The provider relied on the RN's report that the resident was stable and did not recommend hospital transfer at that time. The RN admitted to not following the five rights of medication administration and reported being heavily distracted during the medication pass. The resident was found pulseless and without respirations by nursing staff later that evening, and the death was reported to the Medical Examiner's office. The facility's failure to ensure the resident was free from significant medication errors resulted in the identification of an Immediate Jeopardy situation by the Maryland Office of Health Care Quality.
Removal Plan
- Education of all nurses on medication administration with focus on the six-rights medication administration, opioid management, signs of opioid overdose, and in-house escalation protocol.
- Medicine Pass evaluations and competencies will be completed for all licensed nurses. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- Staff will be quizzed on their understanding of the opioid overdose management policy post education. The quizzes will cover key topics, including recognizing the signs and symptoms of opioid overdose, appropriate response protocols, and steps for escalation. Results will be reviewed, and any areas of concern will be addressed through additional training or clarification.
- Nursing staff will be quizzed on their understanding of the medication administration policy post education. The quiz will focus on the rights of medication administration. Any knowledge gaps identified will be addressed through additional training and support.
- Ongoing monthly medication evaluations will be conducted for all licensed nurses and Certified Medicine Aides by DON/designee. Each nurse will undergo a thorough assessment of their medication administration skills. Any identified areas for improvement will be addressed through additional training, and successful completion will be documented in the employee's personnel file.
- The results will be reported by the DON to the Quality Assurance Performance Improvement Committee until 100% compliance is achieved.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,701 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dundalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Future Care Northpoint | 1 mi | ★★★★★ | 1 | 0 |
| Future Care Canton Harbor | 2.9 mi | ★★★★★ | 7 | 0 |
| Autumn Lake Healthcare Post-acute Care Center | 3.4 mi | ★★★★★ | 27 | 0 |
| Autumn Lake Healthcare At Riverview | 3.6 mi | ★★★★★ | 5 | 0 |
| Rossville Rehabilitation And Healthcare Center | 4.5 mi | ★★★★★ | 33 | 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 July 2026) and official state health department websites.