Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Laplata Llc during CMS and state inspections, most recent first.
Failure to notify a resident's responsible party when a wanderguard bracelet was applied and later removed and discontinued. A resident was identified as an elopement risk, and the bracelet was placed on the resident's ankle, but the record lacked documentation that the responsible party was informed. The TAR later showed the bracelet was removed, and there was still no evidence of notification. The DON acknowledged the notification should have occurred.
A resident was documented as an elopement risk and placed in a wanderguard bracelet, but the admission MDS coded the wander/elopement alarm as not used. The MDS Coordinator confirmed she saw the note but forgot to code the device on the MDS.
A resident with CVA-related right hemiplegia and contracture management needs did not have a right hand splint observed during repeated checks after readmission. Records showed OT had previously used the splint for orthotic tolerance and ROM, but the splint order was not resumed after hospitalization, and staff confirmed there was no active order or OT reassessment after return.
Outdated menus were posted outside the nurses' station, and current menus were not available for resident review before meals. A resident stated menus had not been posted for at least a week and that the resident requested a salad because the lunch selection was unknown, only to learn later that another option was available. The FSD said printing problems after a contractor and meal-tracking transition led to the missing menus, and the usual intercom announcement was not made that day.
Incomplete documentation was found for two residents’ records. One resident had a documented fall, but the record lacked details about how the fall occurred, where it happened, the resident’s position afterward, and whether injuries were present; the fall documentation was also found in the EMR Risk section rather than the medical record. Another resident was identified as an elopement risk and placed on a wanderguard, but there was no ongoing charting in progress notes, no timely order, no TAR documentation showing shift checks, and no explanation for discontinuation.
An LPN and RN failed to follow medication administration standards for several residents by not providing privacy, not explaining medications before administration, and not observing consumption of a nutritional supplement. In another event, enteral feeding supplies for a resident were observed dated two days earlier than the survey date, and the DON confirmed the concern. The facility's policy required privacy, MAR review, and observation of resident consumption.
Facility staff failed to complete required annual performance reviews for geriatric nursing assistants. Four of five employee files reviewed were missing current evaluations or had no evaluation documented, and the staff member interviewed confirmed that annual, 60-day, and 90-day reviews were expected but records were still being organized.
Medication administration errors were observed during medication passes, resulting in a 15.63% error rate. An LPN gave insulin in a dose that did not match the active MAR, administered a non-chewable calcium-vitamin D tablet instead of the ordered chewable form, did not offer an ordered PEG laxative, and left a Med Pass supplement unattended at bedside. Another LPN crushed and administered an Oxybutynin ER tablet despite the MAR stating not to crush it.
Unsecured discontinued and discharged-resident medications were found on the medication room counter in the C/D Wing, including Buspirone, Carvedilol, Furosemide, Cyclobenzaprine, Valproic Acid, and Ipratropium-Albuterol Solution. Record review showed one resident’s Buspirone had been discontinued, another resident had been discharged, a third resident’s Valproic Acid had been discontinued, and a fourth resident’s inhalation solution had been completed. The DON and ADON confirmed these medications should have been removed from the med room and returned to the pharmacy and/or destroyed per facility process.
Failure to implement pharmacy MRR recommendations affected multiple residents. One resident had psychotropic meds reviewed with incomplete physician responses on MRR forms, delayed action on a PRN trazodone recommendation, and no documented GDR attempt for an antipsychotic and citalopram. Two other residents had pharmacy recommendations agreed to by the physician but not carried out for loratadine PRN conversion and Lidoderm patch reconciliation, with repeated reviews showing the same issues before the MAR was updated.
Incomplete Psychotropic Medication Consent Forms: Two residents had no scanned Psychotherapeutic Medication Informed Consent Form in the EMR, and their paper charts contained blank forms labeled with their names that were not completed by the facility or signed by the residents. The DON stated the paper copy should be in the unit chart if not scanned, and the ADON confirmed the forms were not completed as required or signed.
Failure to Invite Residents to Care Plan Meetings: Two residents were not properly invited to or documented as attending care plan meetings. One resident reported never attending a meeting, and the record contained no invitation or attendance documentation despite staff stating letters and attendance sheets are used. Another resident, who had a BIMS of 15 and served as his/her own RP, had inconsistent documentation showing some meetings attended or missed, but key care plan records lacked proof that the resident or RP was invited or present.
A resident’s record had no documentation that the facility offered an advance directive or provided education to the resident or RP. Staff said the process was to ask on admission whether the resident had an AD and, if none existed, provide a Maryland AD packet, with Social Services education to be completed within 7 days; however, the Social Services assessment was not completed.
A facility failed to keep the environment in good repair in 2 resident rooms observed during a recertification and complaint survey. A resident room had peeling paint and visible wall repair patches, and another resident room had peeling paint behind and facing the bed plus a nightstand covering that had peeled off. The DON later stated the Maintenance Director was no longer employed and noted the surveyor’s observations during a facility tour.
Facility failed to ensure a resident was free of a chemical restraint when ordered antianxiety, antidepressant, and opioid medications were given without any documented NPI. Surveyors reviewed the MAR, TAR, and medical record and found no order or care plan for a nonpharmacological approach, and the DON confirmed that no alternative interventions had been attempted.
Failure to Provide Written Bed-Hold Policy Notification at Transfer: A resident was transferred to the hospital after a fall, but the record contained no documentation that the resident or RP received written bed-hold policy information at the time of transfer. The DON and admission assistant described a process for providing or mailing the policy, but review of the chart showed no signature, no evidence the resident was unable to sign, and no documentation that the RP or emergency contact was given the information.
The facility failed to develop complete care plans for 2 residents. One resident receiving antianxiety, antipsychotic, and antidepressant medications had care plan interventions for medication monitoring but no specific non-pharmacological interventions, even while a GDR of buspirone was in progress and the resident reported increased anxiety. Another resident with dementia did not have a dementia care plan at all, and the DON later confirmed the omission.
An LPN administered 21 units of insulin to a resident with DM even though the active MAR order directed 18 units daily. The LPN said the MD had verbally increased the dose, but the MAR had not been updated. Policy review showed staff are to verify the MAR against the medication source and properly document verbal orders, and the DON and ADON acknowledged the dose mismatch was a significant med error.
Failure to Coordinate Hospice Disenrollment and Care Plan Updates: A resident receiving hospice services for cardiovascular disease and end-of-life care remained listed as on hospice in the care plan and facility matrix even after hospice disenrollment. Staff interviews showed the facility relied on hospice to send written notice, but no formal disenrollment documentation was in the chart, the MDS team was notified late, and the census was not updated timely.
QA committee participation was inconsistent, with the IP missing one meeting and the Medical Director absent from multiple monthly meetings. The Administrator stated QA meetings were supposed to occur monthly but had not been held consistently, and only two meetings had taken place during her first two months in the role. The Administrator also confirmed the IP was off sick for one month after an accident and no coverage was arranged.
A resident with dementia, severe cognitive impairment, poor gait/balance, and incontinence experienced multiple falls, including two hip fractures, while staff failed to consistently update and individualize the fall care plan or implement ordered interventions. Although the care plan called for root cause review of each fall and a toileting program, several documented falls were never added to the care plan, no new interventions were implemented, and the toileting program was not carried out. The care plan lacked any intervention specifying the needed level of supervision, despite the resident’s impulsivity and frequent unassisted attempts to get up. After a fall resulting in a left hip fracture and subsequent readmission, the only new intervention was to place the wheelchair by the bed, which staff had already been doing, and there was still no documented fall analysis. Observation of the resident’s room revealed additional unaddressed hazards, including a high bed without fall mats, cluttered and low-lit areas, obstructed space preventing wheelchair placement by the bed, and a closed curtain that blocked staff visibility, all contributing to the cited deficiency in accident prevention and supervision.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment across multiple units and common areas. Hallways on several wings were lined with w/c, geriatric chairs, mechanical lifts, dressers, boxes, and other equipment, while handrails were used to store items such as gloves, trash bags, paper cups, paper towels, and hand sanitizer drip trays. A trash bag with linens was left on a resident room floor, and a bedside commode with an uncovered urine hat was stored at the end of a hallway. In the main dining room, large sheets of plastic were taped to the ceiling, partially covering vending machines and concealing building supplies. Shower rooms were used for storage of w/c, geriatric chairs, beds, clothing bags, and maintenance equipment, leaving only limited shower stalls accessible. An LPN confirmed that staff routinely store residents’ mobility devices in hallways, rooms, and shower areas.
A resident with a history of frequent refusals of medications, vitals, and nursing care had a care plan and physician order directing staff to notify the resident’s representative (RR) whenever treatments or procedures were refused. Despite ongoing daily medication refusals and two documented falls followed by ordered but refused x‑rays, labs, and imaging, records showed that while physicians were notified, the RR was not. Nursing notes later documented a change in the resident’s responsiveness, and the on‑call physician ordered continued monitoring and respect for the resident’s refusal of labs, yet there was still no documented contact with the RR as required by the care plan and orders. The resident was subsequently transferred to the hospital with a diagnosis of sepsis, and the DON could not provide documentation that the RR had been notified of these refusals or condition changes.
A resident repeatedly reported that current incontinence briefs were leaking more than previous ones, causing urine odor on clothing and leading to a missed facility event, along with concerns about missing medical shoe boots and bothersome construction odors. The first grievance was marked resolved without addressing the leaking brief issue, and a second grievance was closed after deciding to add a pad under the brief, without investigating the cause of the leakage or ensuring an effective intervention. The resident stated that staff were not responsive to these complaints, and the NHA, acting as Grievance Officer, acknowledged that the initial concern was not addressed and that the second grievance was not properly investigated.
An activity assistant asked a group of residents if they wanted to listen to music, then played it despite most declining, using music a resident described as derogatory, inappropriate, and excessively loud. This triggered a verbal confrontation between the assistant and a resident, escalating into yelling and cursing until a supervisor intervened and removed the staff member from the area. The recreation director reported prior complaints from this resident about the same staff member’s music, and the staff member’s file showed recent discipline for negative interactions in which a resident was singled out and became upset. Surveyors substantiated this as verbal abuse and failure to treat a resident with respect.
The facility failed to prevent misappropriation of controlled medications and to ensure proper destruction procedures were followed. A former unit manager RN removed and destroyed oxycodone from a med cart without a second licensed nurse present, then left early without notifying the nurse assigned to that cart. Later, another RN found the controlled substance destruction form on the former manager’s desk with signatures suggesting two staff had witnessed destruction, but one staff member reported he had only witnessed his own medications being wasted, not the additional narcotics listed. Surveyors reviewing Unit A narcotic logs found multiple days with missing entries, and the DON acknowledged that the facility’s investigation did not identify which residents’ medications were destroyed, did not verify whether medications documented as sent home or destroyed had actually been handled as recorded, and relied only on the fact that medications were signed off to conclude no other residents were affected.
The facility failed to meet required timeframes for reporting abuse allegations and misappropriation of medication to the SA and did not fully document when and to whom these concerns were reported. In one case, a resident’s family member reported during a care plan meeting that two male therapists had kicked the resident, but documentation of the time of the allegation, the chain of reporting, and the person notified was incomplete, and the report to the SA occurred later that day. In another case, staff reported concerns about misappropriation of a resident’s medication, but the SA was not notified until eight business days later, even though this incident was later classified as misappropriation of resident medication, a form of abuse.
The facility failed to thoroughly investigate and properly document multiple allegations of neglect, abuse, and misappropriation. One resident with chronic pain and no cognitive impairment reported not receiving pain meds for 24 hours, not getting preferred daily showers, and experiencing trauma triggers, yet the investigation lacked a resident statement, interviews with other residents or staff, and any documented inquiry into bathing preferences, pain control, or trauma screening. Another resident with a stroke and mild cognitive impairment alleged being kicked in the chest and stomach by two male staff, but the initial report omitted to whom the allegation was reported, the SSD’s statement lacked dates and times, and staff interviews were incomplete. In a separate incident, an RN unit manager destroyed two sheets of oxycodone without a witness, and the facility did not determine whose meds were destroyed or audit other narcotics documented as sent home or destroyed on that unit, relying only on the fact that medications were signed off.
Staff failed to consistently complete and sign end-of-shift narcotic count verifications for one medication cart on a unit, leaving multiple days without required two-nurse signatures despite facility policy requiring this process. A prior internal concern about alleged improper wasting of narcotics without a witness led surveyors to review narcotic logbooks and compare them with staff schedules, revealing that even when nurses worked double shifts, narcotic logs were often not signed between shifts. The DON acknowledged instructing staff working doubles to sign for both shifts, and facility policy required daily visual audits and spot checks of controlled substance documentation, but the shift-to-shift verification process was not maintained.
Surveyors observed a medication cart left unattended near a nursing station with insulin syringes, hypodermic needles, and a Budesonide inhaler on top, while the assigned RN was in a nearby bathroom and not supervising the cart. A ward clerk and unit manager were present in the area but were not responsible for the cart. During this period, two independently mobile residents were on the opposite side of the nursing station, out of direct staff view, including a resident with Alzheimer's disease and a care plan for eating and chewing inanimate objects. The unsecured medications and administration instruments on the unattended cart in proximity to these vulnerable residents constituted the cited deficiency.
The facility did not maintain three years of survey results for residents, families, and visitors to review. A surveyor’s review of the survey binder in the front lobby showed that it did not contain the required three years of survey reports. In an interview, the NHA confirmed he had reviewed the binder and stated that the facility’s standard was to keep only one year of survey results available, resulting in noncompliance with requirements for public access to survey findings.
A resident was transferred to the hospital without the required care plan goals or documentation being sent, as confirmed by medical record review and staff interviews. The DON made the transfer decision due to behavioral concerns, but the resident had not been assessed by psychiatric services or a physician, and the facility social worker was not involved in the process. Hospital staff reported receiving no paperwork or belongings with the resident.
A resident was transferred to the hospital due to behavioral issues without receiving the required discharge notice, care plan information, or documentation of appeal rights. The DON made the transfer decision without input from psychiatric services or the medical director, and hospital staff reported not receiving necessary paperwork or a bed hold notice.
A resident was transferred to the hospital without the required documentation, care plan goals, or belongings, and neither the resident nor their responsible party received necessary information prior to transfer. The transfer decision was made by the DON due to behavioral concerns, without assessment by a facility physician or psychiatric services, and hospital staff confirmed that no paperwork or bed hold notice was provided.
A resident was transferred to the hospital due to behavioral concerns without being provided a written bed hold notice or the required transfer documentation. Facility staff, including the DON and hospital liaison, confirmed that no paperwork or belongings were sent with the resident, and hospital social workers reported not receiving any bed hold notice or transfer information.
A resident was transferred to the hospital due to behavioral issues without being issued an involuntary discharge notice or having required transfer documentation and care plan information sent. The DON made the decision to transfer the resident, and hospital staff reported that no paperwork, belongings, or bed hold notice were provided, and the resident was not assessed by facility psychiatric services or a physician prior to transfer.
The facility failed to provide warm palatable food to residents, as evidenced by cold meals and inadequate measures to maintain food temperature. A resident confirmed the issue, and test trays showed food temperatures below acceptable levels. The facility lacked sufficient heated pellets and a pellet warmer, contributing to the deficiency.
The facility failed to accurately assess residents' use of side rails and functional status on the MDS. A resident had side rails documented as 'not used' despite their presence, and another had a physician order for side rails, yet the MDS indicated 'not used'. Additionally, a third resident had family consent for side rails, but the MDS inaccurately reported 'not used'. These inaccuracies were noted during a survey and discussed with the DON.
Facility staff failed to follow CDC guidelines for PPE removal during a COVID-19 outbreak. A GNA was observed removing PPE in the hallway instead of inside the resident's room and did not sanitize hands afterward. The GNA also took two food trays into a room without changing gloves or gown between residents. Interviews revealed a lack of recent PPE training and monitoring of staff compliance with infection control protocols.
The facility failed to maintain safe and accessible hallways in Units A, B, and D, with clutter including wheelchairs, chairs, and carts obstructing pathways and handrails. This clutter, due to maintenance activities and insufficient room space, persisted over several days despite being reported to management, raising concerns about emergency evacuation and resident safety.
A facility failed to honor a resident's advance directive, which requested all life-extending measures, including a gastrostomy tube for nutrition. Despite the resident's repeated hospitalizations for aspiration pneumonia and dehydration, the MOLST form indicated no artificial nutrition, influenced by the healthcare agent's opposition. This discrepancy was not addressed, leading to a deficiency in care.
A resident reported being hit by staff members, but the facility delayed reporting the abuse allegation to the state agency by 5 hours, exceeding the required 2-hour timeframe. The incident was brought to the attention of the DON during a complaint survey.
A facility failed to thoroughly investigate an alleged abuse incident where a resident was reportedly struck by a receptionist. The investigation did not include interviews with the resident's roommate or other residents, and the Assistant Director of Nursing could not recall who was interviewed. The Director of Nursing was informed of these findings.
Two residents were unnecessarily monitored with elopement deterrent devices due to the facility's failure to reassess their elopement risk after significant changes in their conditions. Despite assessments indicating low risk, the residents continued to be monitored with wanderguards, a decision made by the DON and Unit Managers. Interviews revealed a lack of clarity on the necessity of these devices.
A resident's care plan was not updated after multiple incidents of g-tube dislodgement, despite the facility's protocol requiring updates following a change in status. The resident needed hospital transfers for g-tube replacement on several occasions, but the care plan was last updated in September 2023. Interviews confirmed that unit managers are responsible for such updates, but this was not done in 2024.
The facility failed to document ADL care for two residents dependent on staff for bowel and bladder care. One resident, requiring extensive assistance, had care documented only twice out of ten potential times. Another resident, dependent due to comorbidities, had no care documented over several shifts. Staff interviews confirmed that ADL records should not have blanks.
The facility did not ensure trauma-informed care for a resident with a history of trauma, as no assessment or care plan was completed upon admission. A social worker confirmed that trauma-informed care assessments were not administered at the time of admission, although they were part of the facility's protocol. An assessment and care plan were only implemented after a complaint investigation.
The facility failed to properly assess and reassess two residents for bed rail use, leading to deficiencies in care. One resident experienced multiple falls and injuries without a reassessment after a change in functional status, while another continued using bed rails against assessment recommendations, resulting in a forehead injury. Staff interviews confirmed the use of bed rails to prevent falls, but there was no evidence of alternative safety measures being considered.
A facility failed to administer medications in accordance with professional standards, resulting in a resident receiving medications late on multiple occasions. Medications such as Tylenol, Prednisone, Metoprolol Tartrate, and Finasteride were administered outside the prescribed 1-hour time frame, as revealed in a medication administration audit. These findings were confirmed through observation, record review, and interviews, and discussed with the DON.
A facility failed to notify a physician of lab results for a resident with multiple comorbidities, including diabetes and anemia. A repeat CBC was ordered by an NP, but the lab report was not available in the medical record, and no physician was notified of the results. The lab report, containing several flagged results, was only reviewed 13 days later during a subsequent visit. The Medical Director confirmed the delay, and the report had to be printed by the DON upon request.
Failure to Notify Responsible Party of Wanderguard Application and Discontinuation
Penalty
Summary
Facility staff failed to notify a resident's responsible party when a wanderguard bracelet was applied and when it was later removed and discontinued. Resident #6 was identified as an elopement risk by the night supervisor, and a wanderguard bracelet was placed on the resident's right ankle on 2/21/26 at 4:38 PM. The medical record did not contain documentation that the responsible party was notified of the bracelet being applied. The resident's May 2026 TAR documented that the wanderguard bracelet was removed on 5/8/26, but progress notes and assessments did not show that the responsible party was notified of the removal and discontinuation. The DON acknowledged that the responsible party should have been notified when the wanderguard bracelet was applied and when it was removed and discontinued.
Inaccurate MDS Coding for Wander Alarm Use
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for Resident #6. During review of facility reported incident 3018652, the resident’s medical record, and staff interview, it was found that a 2/21/26 nurse’s note documented the resident as an elopement risk and stated that a wanderguard bracelet was placed on the resident’s right ankle. However, the admission MDS with an ARD of 2/27/26, Section O, Restraints, P0200A, coded the wander/elopement alarm as not used. The facility did not capture the use of the wanderguard on the MDS. During interview, the MDS Coordinator confirmed the finding and stated she had seen the note but forgot to code it on the MDS.
Failure to Resume Right Hand Splint for Contracture Management
Penalty
Summary
The facility failed to reassess and continue an established intervention for contracture management after a resident’s readmission from the hospital. Resident #2 had a history of CVA/stroke with right-sided hemiplegia related to a head injury, and the comprehensive care plan included use of a right hand splint to prevent contractures as ordered. During observations on multiple occasions, the resident was in bed and a right hand splint was not observed. Record review showed the resident had received OT services for contracture management, orthotic tolerance, and passive and active assisted ROM, and at discharge from OT the resident was documented as tolerating a resting hand splint on the right hand for up to 3.5 hours. The TAR showed a physician order dated 4/23/26 to apply the right hand splint when out of bed, but the order was not resumed after the resident’s readmission on 5/19/26 and was not active as of 6/10/26. Staff interviews confirmed OT did not evaluate the resident after readmission, the resident did not have an active splint order, and the splint was not being applied.
Outdated Menus Not Posted for Resident Review
Penalty
Summary
The facility failed to ensure residents were informed of meal selections by posting current menus for resident review prior to meal service. During an interview, Resident #8 stated current menus had not been posted for at least one week and residents were unable to review meals in advance. Resident #8 reported requesting a salad for lunch because the resident did not know what meal was being served, and then learned at lunch that a different meal option was available that the resident would have chosen if it had been known beforehand. On observation, three menus posted outside the nurses' station on the 200 unit were dated 6/1/26, 6/2/26, and 6/3/26, even though the survey occurred later in the month. The Food Service Director stated the facility had recently transitioned to a new food service contractor and meal-tracking system and had difficulty printing menus, which resulted in current menus not being posted. The FSD also stated the lunch meal for the day had been changed because food items were unavailable and that menu announcements over the intercom were not made that day because she was on a telephone call with an outside food vendor. During the tour, the FSD acknowledged the posted menus were outdated and should have been removed.
Incomplete Documentation of Fall and Wanderguard Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for 2 residents reviewed during a complaint survey. For one resident, a change-in-condition note documented a fall but did not include documentation of how the resident fell, what precipitated the fall, where the fall occurred, the resident’s position after the fall, or whether any injuries were present. The fall was later confirmed by the ADON, who also provided a copy of the fall documentation located in the electronic medical record’s Risk section, which was identified as not being part of the resident’s medical record. The DON and NHA both agreed there should have been more documentation in the medical record. For another resident, a nurse documented that the resident was an elopement risk and that a wanderguard bracelet was placed on the resident’s ankle, but there was no further documentation in progress notes, nursing notes, or physician notes about the wanderguard. The physician’s order for the wanderguard was not written until later, and the February TAR did not document that the device was monitored and checked for placement on all shifts during the period it was in use; the March TAR also lacked documentation until the order date. The wanderguard was later discontinued, but the medical record did not include documentation explaining why it was discontinued. The DON agreed the documentation should have been on the TAR and confirmed the survey findings.
Failure to Follow Standards During Medication Administration and Enteral Feeding Care
Penalty
Summary
The facility failed to provide services that met professional standards of practice during medication administration and enteral feeding care for multiple residents. The report identified deficiencies for Resident #11, Resident #50, Resident #124, and Resident #32 during the recertification and complaint survey. The facility's own medication administration policy required privacy, review of the MAR, and observation of resident consumption of medication. For Resident #11, the surveyor observed a water bag dated 4/26/26 at 8:00 PM and a bottle of Jevity 1.5 enteral feeding also dated 4/26/26 at 8:00 PM. The resident had an order for continuous enteral feeding via pump at 60 mL per hour for 8 hours per day, with downtime from 4:00 AM to 8:00 PM. The DON confirmed the dating concern and stated she had begun an in-service for enteral feedings and provided education for the nurse assigned to the resident. During medication administration observations, an LPN administered medications to Resident #50 without pulling the privacy curtain and without explaining the medications before administration. The same LPN administered Med Pass 2.0 to Resident #124 without explaining the medication and left 120 mL of the supplement unattended at the bedside without confirming the resident had consumed it. For Resident #32, an RN administered Hydrocodone/Acetaminophen from the medication cart in the hallway while at least one other resident and one staff member were passing through the area. The RN stated medications are normally administered in residents' rooms, and the DON and ADON later acknowledged the concerns related to privacy, explanation of medications, and observing medication consumption.
Missing Annual Performance Evaluations for Geriatric Nursing Assistants
Penalty
Summary
Facility staff failed to complete required performance reviews of geriatric nursing assistants at least once every 12 months. During review of employee records, 4 of 5 files examined showed missing or overdue evaluations: Employee #27 had evaluations dated 06/08/2025 and 04/24/2026, Employee #28 had one evaluation dated 02/07/2025, Employee #29 had no documented performance evaluation, and Employee #30 had no employee record available for review. Staff #15 stated that annual evaluations are expected, along with 60-day and 90-day evaluations for new hires, and confirmed the hire dates for the employees reviewed. Staff #15 also stated she had been in the position for one year and was in the process of organizing records, and during the survey the record for Employee #27 was not initially found in the personnel files and was later reported to be at her desk.
Medication Error Rate Exceeded 5% During Observed Medication Passes
Penalty
Summary
The facility failed to be free of a medication error rate of 5% or greater after surveyors observed multiple medication administration errors during the annual/complaint survey. The report states that the observed errors resulted in a medication error rate of 15.63 percent and involved medications administered to residents with diabetes, constipation, nutritional supplementation needs, bone health supplementation, and overactive bladder treatment. On 04/30/2026, an LPN administered 21 units of insulin to a resident with diabetes, while the active MAR directed 18 units one time daily at 0800. The LPN stated that the MD had verbally instructed her the previous day to increase the dose to 21 units, but the MAR had not yet been updated. During the same medication pass, the LPN administered a non-chewable Calcium-Vitamin D tablet to a resident whose MAR ordered a chewable formulation, did not ask the resident whether he/she wished to take the ordered Polyethylene Glycol powder, and left Med Pass 2.0 unattended on the resident’s bedside table after exiting the room. On 05/01/2026, another LPN prepared and administered Oxybutynin Chloride ER 24-hour tablets for a resident with dysphagia, despite the MAR stating, “DO NOT CRUSH MEDICATION.” The LPN crushed the extended-release tablet along with the resident’s other medications and then administered the crushed medication. The DON and ADON were later informed of the observations and acknowledged that verbal insulin orders should not be administered until the MAR and physician orders are updated and verified, medications should not be left unattended at bedside, the formulation administered should match the physician order, and extended-release medications should not be crushed.
Unsecured Discontinued and Discharged-Resident Medications Found in Medication Room
Penalty
Summary
Drugs and biologicals in the facility were not properly removed from the medication room when they were discontinued, completed, or no longer needed for residents. During an observation of the C/D Wing medication room, several blister packets of medications were found sitting unsecured on the medication room counter, each still labeled with resident names and medication information. The medications observed included Buspirone 5 mg for Resident #37, Carvedilol 12.5 mg, Furosemide 40 mg, and Cyclobenzaprine 10 mg for Resident #138, Valproic Acid 250 mg for Resident #122, and Ipratropium-Albuterol Solution for Resident #5. Record review showed that Buspirone for Resident #37 had been discontinued, Resident #138 had been discharged from the facility, Valproic Acid for Resident #122 had been discontinued, and Ipratropium-Albuterol Solution for Resident #5 had been completed. During interview, the DON and ADON were shown the medications on the counter and acknowledged that discontinued medications and medications belonging to discharged residents should have been removed from the medication room and returned to the pharmacy and/or destroyed according to facility process. The DON and ADON then gathered the medications to be returned and/or destroyed.
Failure to Implement Pharmacy MRR Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy medication regimen review recommendations were implemented for 3 of 6 residents reviewed. For Resident #3, the MDS documented routine antipsychotic use without a gradual dose reduction attempt and without physician documentation that a GDR was clinically contraindicated. The resident had an active order for Rexulti 2 mg daily for depression, and pharmacy reviews identified concerns with psychotropic medication use and a PRN trazodone order that remained active after the pharmacist recommended discontinuation or a stop date. The physician response sections on the MRR forms were left incomplete on multiple reviews, and one recommendation to discontinue trazodone was not acted upon until about two months after the initial pharmacy recommendation. Resident #3 also had a pharmacy recommendation regarding citalopram 10 mg daily that stated a GDR should be attempted during at least two separate quarters during the first year of psychopharmacological use or after initiation by the facility. The physician response section was again incomplete, with handwritten notation stating "cont some," and the medication was later discontinued. During interview, the DON acknowledged concerns about incomplete physician completion of the Agree, Disagree, and Other sections and the delay in addressing the pharmacy recommendation beyond the facility policy timeframe. The Medical Director stated that she generally did not change outpatient psychiatric medications unless clinically indicated and reported that the resident declined dose reductions. For Resident #14, pharmacy recommended changing loratadine 10 mg to PRN because it had not been routinely administered, and the physician agreed, but the recommendation was not implemented until months later after it was repeated. For Resident #15, pharmacy repeatedly recommended reconciling Lidoderm patch use because documentation showed the patches were being left on for almost 24 hours instead of the recommended 12 hours on and 12 hours off. Although the physician agreed to each recommendation and signed them, the MAR showed the recommendation was not implemented until after multiple repeated pharmacy reviews. The DON confirmed the delay in implementing the pharmacy recommendations for Residents #14 and #15.
Incomplete Psychotropic Medication Consent Forms
Penalty
Summary
The facility failed to ensure residents were informed of the risks and benefits of psychotropic medications. During the annual recertification survey, record reviews and interviews showed that for Resident #7 there was no Psychotherapeutic Medication Informed Consent Form scanned into the electronic medical record. The DON stated that if the consent form was not scanned, the paper copy would be in the physical chart on the unit, but the paper chart contained a blank form labeled with the resident’s name that was not completed by the facility or signed by the resident. The ADON confirmed the form was not completed as required or signed. A similar finding was identified for Resident #2. The electronic medical record did not contain a scanned Psychotherapeutic Medication Informed Consent Form, and the paper chart on the unit contained a blank form labeled with the resident’s name that was not completed by the facility or signed by the resident. During an interview with the DON and ADON, concerns were addressed about the blank and unsigned form found in the resident’s paper chart.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite residents to their care plan meetings for 2 of 2 residents reviewed during the recertification survey. Resident #8 reported that he/she had never attended a care plan meeting and did not know the Social Worker. Record review showed the resident was admitted to the facility on an unspecified date, but there was no documentation that the resident was invited to or attended any care plan meetings. Staff stated that care plan meeting notifications are normally provided by written letters for long-term care residents and in-person communication for short-term residents, with attendance documented on signed attendance sheets, but no such documentation was found for Resident #8. Although care plan signature sheets dated 10/15/2025 and 01/21/2026 were later submitted, they did not show evidence of the resident's attendance or invitation. Resident #6 reported having not had any meeting at the facility and stated he/she had been there on and off for about four and a half years. Record review showed a re-admission on an unspecified date and a BIMS score of 15. Social work notes documented that the resident was unable to attend one care plan meeting due to a COVID outbreak, was present at another meeting, and was invited but did not attend a later meeting. However, only one care plan signature sheet was found in the record, and a signature sheet dated 11/14/2023 showed the resident's brother attended even though the resident served as his/her own responsible party. Staff confirmed the resident was bedbound and able to participate and sign the care plan signature sheet, but there was no documentation that the resident or responsible party attended the 11/14/2023 meeting, and a later signature sheet dated 05/28/2025 also contained no signature from the resident or responsible party.
Failure to Offer Advance Directive Information
Penalty
Summary
The facility failed to ensure that residents were offered written information regarding advance directives. During review of Resident #120’s medical record, there was no documentation in the EHR showing that the facility offered an advance directive or provided education about advance directives to the resident or the resident’s Responsible Party. This was identified during the recertification survey process for 1 of 3 residents reviewed for advance directives. Staff interviews showed that the facility’s process was to ask on admission whether a resident had an advance directive and, if not, to provide a Maryland Advance Directive packet. Staff also stated that the Social Services admission assessment, which includes education on advance directives for the resident and/or Responsible Party, was to be completed within one week of admission. However, surveyor review with staff confirmed that the Social Services Assessment had not been completed, and staff stated they were not sure why it was not completed.
Environment Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure that the environment was in good repair for 2 of 7 resident rooms observed during the recertification and complaint survey. In Resident #10’s room, the surveyor observed an oval-shaped area where paint had peeled from the wall behind the bed, along with 2 large white patches on the wall in front of the bed from a wall repair. In Resident #15’s room, the surveyor observed peeling paint behind the bed and on the wall facing the bed, and the top right side of the nightstand covering had peeled off. During a later interview, the DON reported that the Maintenance Director was recently no longer employed at the facility, and the surveyor, DON, and ADON toured the facility while the surveyor pointed out the observations and the DON took notes.
Failure to Document Nonpharmacological Approach for Psychotropic and Opioid Medications
Penalty
Summary
Facility failed to ensure Resident #15 was free of a chemical restraint when the resident received ordered antianxiety, antidepressant, and opioid medications without any documented nonpharmacological approach. During record review of the resident’s MAR on 04/29/2026, surveyors found orders for these medications, and review of the MAR and TAR did not show an order for a nonpharmacological approach. A review of the resident’s medical record also did not reveal a care plan for a non-pharmacological approach related to the antianxiety, antidepressant, and opioid medications. During an interview on 05/01/2026, the surveyor discussed the concern that Resident #15 had received these medications, but the facility had not implemented alternative interventions such as a nonpharmacological approach. The DON stated she would investigate and return, and then confirmed that no alternative interventions had been attempted.
Failure to Provide Written Bed-Hold Policy Notification at Transfer
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to the resident and/or the resident's representative when Resident #131 was transferred to an acute care hospital after a fall. Record review showed the resident was admitted to Maryland University [NAME] Regional Center on 04/04/2026, and the medical record contained no documentation that written bed-hold information was given at the time of transfer. During interviews, the DON stated that the bed-hold policy is provided to the resident if capable, or mailed to the resident's RP via certified mail if not, and that the admission Assistant follows up with the family or RP. The admission Assistant stated that the policy is mailed to the resident's family/RP when the resident is unable to sign or receive it and a copy is kept in a binder. However, review of Resident #131's record with the DON and admission Assistant found no signature or documentation showing the resident or RP received the bed-hold policy at transfer, and the policy was mailed to the resident's home address while the resident was hospitalized. There was no documentation that the resident was unable to sign at transfer, and no documentation that the emergency contact or RP was provided the policy.
Incomplete Care Plans for Medication Management and Dementia
Penalty
Summary
The facility failed to ensure a comprehensive resident care plan was developed and implemented for 2 of 28 residents reviewed. For Resident #7, the medical record showed orders for an antianxiety medication, an antipsychotic medication, and an antidepressant medication for anxiety and bipolar disorder. Progress notes documented that the resident was trialing a gradual dose reduction of buspirone and had complained of increased anxiety while the GDR was in progress. The care plan included goals and interventions related to the medications, such as administering them as ordered and monitoring for adverse reactions, but it did not include specific non-pharmacological interventions. During interview, the DON and ADON discussed the concern that the resident's care plan did not contain specific non-pharmacological interventions. For Resident #14, the record showed a diagnosis of dementia. A review of the care plan found that the resident did not have a care plan for dementia. During interview, the surveyor raised the concern with the DON, who stated she would investigate and return. The DON later confirmed that Resident #14 did not have a dementia care plan.
Significant Medication Error with Insulin Administration
Penalty
Summary
A significant medication error occurred during medication administration for Resident #50, who had diabetes mellitus and was receiving insulin. During an observed medication pass, an LPN administered 21 units of insulin into the resident’s right arm and stated she was giving 21 units. After the pass, the surveyor reviewed the active MAR with the LPN and found that the order directed staff to administer 18 units of insulin one time daily at 0800. The LPN stated that the MD had verbally instructed her the previous day to increase the dose from 18 units to 21 units, but the MAR had not yet been updated. Record review of the facility’s Medication Administration policy stated that staff are to compare the medication source with the MAR to verify the resident name, medication name, form, dose, route, and time. Review of the Verbal/Telephone Orders policy stated that prescribed orders are to be repeated back for clarification, entered into the medical record, and include the date, time, resident name, complete order, and signatures. During interview, the DON and ADON acknowledged that administering a different insulin dose than what was listed in the active order was a significant medication error and confirmed that verbal insulin orders should not be administered until the MAR and physician orders are updated and verified.
Failure to Coordinate Hospice Disenrollment and Care Plan Updates
Penalty
Summary
The facility failed to coordinate with hospice representatives to ensure that hospice care and facility services were aligned for a resident who had been admitted to Hospice of the Chesapeake for cardiovascular disease and end-of-life care. Although the resident’s care plan continued to identify hospice services and the facility’s matrix indicated hospice involvement, the Director of Nursing stated the resident had been disenrolled from hospice services, and the care plan and census information were not updated to reflect that change. Record review and staff interviews showed no documentation in the medical record that the resident was formally disenrolled or discharged from hospice services. Staff stated that a significant change assessment was required within 14 days of hospice admission or disenrollment, but the MDS department was not notified of the disenrollment until weeks later by the Business Office Manager, and the census line was not updated until later still. The Business Office Manager stated the facility relied on hospice to send a notification letter confirming disenrollment, and the DON confirmed hospice verbally notified the facility, but the facility did not follow up to obtain the supporting paperwork.
QA Committee Lacked Required Participation
Penalty
Summary
The facility failed to ensure that the Infection Preventionist and Medical Director participated in the Quality Assessment and Assurance (QA) committee. Review of the monthly QA sign-in sheets from 3/20/2025 through 3/20/2026 showed that the Infection Preventionist did not attend the 2/27/2026 meeting, and the Medical Director did not attend the monthly meetings on 3/20/2025, 8/19/2025, 9/23/2025, 12/29/2025, and 2/27/2026. During an interview on 05/04/2026, the Administrator stated that QA meetings are supposed to occur monthly but had not been conducted consistently prior to her arrival, and that only two meetings had been held during her two months in the role. The Administrator also confirmed that the records did not show the Medical Director attended the listed meetings and stated the Infection Preventionist had been off sick for one month after an accident, with no coverage arranged during that time.
Failure to Analyze Recurrent Falls and Implement Adequate Supervision and Environmental Controls
Penalty
Summary
Facility staff failed to identify and evaluate factors contributing to a resident’s recurrent falls and did not ensure appropriate interventions were implemented to prevent future occurrences. The resident had dementia with severe cognitive impairment, poor gait and balance, poor safety comprehension, incontinence, and a history of falls, and was assessed as high risk for falls. A fall care plan initiated months earlier included environmental decluttering, adequate lighting, appropriate footwear, and fall mats, with a goal to keep the resident free of falls. After a right hip fracture from a fall, the care plan called for a toileting program and for each fall to be reviewed for root cause and for the cause to be removed. However, the care plan did not include any intervention specifying the level of supervision needed to prevent falls. Multiple subsequent falls were documented on Change in Condition (CIC) forms, but these events were not consistently incorporated into the care plan, and new interventions were often not added. Falls on 6/16/25 and 7/1/25 were not listed on the care plan, no new interventions were implemented, and there was no evidence that staff reviewed these falls to determine their causes, despite the care plan directive to do so. A toileting program ordered to prevent falls was not implemented, as confirmed by review of the physician’s orders, MAR, and TAR, and by interview with an LPN who stated the resident was not on a toileting program. A later fall on 12/23/25 was added to the care plan, but only one new intervention (ensuring the bed was locked and in low position) was documented, again with no evidence of a fall review or root cause analysis. On 12/31/25, the resident sustained another fall, was found on the floor near the bathroom doorway while staff were passing lunch trays and administering medications, and was subsequently diagnosed with a left hip fracture requiring surgical intervention. After readmission, the fall care plan was updated with only one intervention to place the wheelchair beside the bed, an action staff had already been performing per LPN interview, and there was still no documented review of the fall for root cause or any intervention addressing the level of supervision needed. Observation of the resident’s new room showed additional unaddressed hazards: the bed was too high, there were no fall mats, the wheelchair was not beside the bed and there was no space to place it there, the curtain was closed preventing staff from seeing the resident, the room was far from the nurses’ station, and the roommate’s side was cluttered with low lighting and items protruding into the walkway. These conditions, combined with the resident’s impulsivity, poor safety awareness, and frequent attempts to get up unassisted, reflected the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.
Cluttered Hallways, Shower Rooms, and Dining Area Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment on all nursing units and in common areas. During a tour of the C and D units, surveyors observed a partially disassembled hand sanitizer dispenser lying on a PPE cart, wheelchairs, geriatric chairs, and mechanical lifts stored in multiple hallways, and paper cups and a plastic drip tray placed on handrails. Additional items, including a box of gloves and a green mesh bag containing trash bags, were also stored on handrails outside resident rooms. On the A and B units, surveyors observed a trash bag with linens on the floor beside a resident bed, multiple hand sanitizer drip trays and a partial roll of paper towels on handrails, and a mesh bag with trash bags hanging from a handrail. At the end of one hallway, a bedside commode with an uncovered urine hat was present, and the short A wing hallway contained multiple dressers, boxes, and a large trash can stored near the recreation room. Wheelchairs, geriatric chairs, and mechanical lifts were stored in each hallway on the unit. In the main dining room, where residents eat meals and participate in activities, large pieces of plastic were hanging from the ceiling, secured with blue painter’s tape, partially covering vending machines and concealing a large assortment of building supplies. On a subsequent tour, an open, uncovered linen cart with linens and wash basins was observed between resident rooms, along with a box of gloves on the handrail and additional wheelchairs, geriatric chairs, a room chair, and mechanical lifts lining the hallways. One wheelchair contained basins, bleach wipes, toiletries, and trash bags on the seat, and a housekeeper had difficulty maneuvering a cleaning cart between these items and a medication cart. An LPN reported that staff store residents’ wheelchairs and geriatric chairs in hallways, resident rooms, and shower rooms. In the C and D shower room, wheelchairs, geriatric chairs, and a shower bed with large trash bags of clothing and shoes occupied shower stalls, while other stalls contained shower chairs and stretchers. In the A and B shower room, men were moving a bed from the shower room, and the women’s side was full of maintenance equipment; another room had a bed with bags of clothing, and the men’s side had three geriatric chairs blocking a back shower stall, leaving only two shower stalls accessible.
Failure to Notify Resident Representative of Treatment Refusals and Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative (RR) of changes in condition and refusals of treatment, despite a specific care plan and physician order requiring such notification. The RR had requested during a care plan meeting that staff call her whenever the resident refused medications, treatments, vitals, or procedures, and this request was incorporated into the care plan and entered as a physician order on the MAR to be acknowledged every shift from admission to discharge. Medical record review showed that the resident had ongoing, daily refusals of medications throughout the stay, and although the attending physician was notified, there was no documentation that the RR was informed of these refusals as required. Further review of the nursing progress notes showed that the resident experienced a fall in late summer, after which x‑rays and laboratory tests were ordered due to observed swelling; these tests were refused and never completed, and there was no documentation that the RR was notified. Later in the stay, the resident had another witnessed fall, and subsequent labs and imaging, including a urinalysis, were ordered and again refused in line with the resident’s documented history of refusals. The following day, nursing notes documented a change in condition with the resident being less responsive. The on‑call physician was notified and ordered monitoring and to respect the resident’s refusal of labs, with instructions to re‑offer if the condition changed or the resident became more agreeable. At no time, according to the record and interviews, was the RR notified or contacted to come in and assist, despite the existing care plan and orders. The resident was later transferred to the hospital for an extended stay with a diagnosis of sepsis, and the DON was unable to provide additional documentation showing that the RR had been notified of the refusals or changes in condition related to the falls and subsequent orders.
Failure to Adequately Investigate and Resolve Resident Grievances About Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and resolve a resident’s grievances related to incontinence care and other concerns. Record review showed that on 12/9/25 three concerns about Resident #10 were reported to social services: the resident’s incontinence briefs were leaking more than previous ones and their clothing smelled of urine more frequently, two medical shoe boots were missing, and construction odors were bothering the resident. The grievance form indicated that the Nursing Home Administrator (NHA) investigated the grievance and signed it as resolved on 12/10/25, but the written response did not address the concern about the leaking incontinence briefs. A second grievance dated 12/24/25, completed by Unit Manager #4, documented that the same resident again reported leaking incontinence briefs that caused urine odor on their clothing and led them to miss a facility event. The resident stated that the previous briefs did not leak and that they had been complaining without anyone listening. The follow-up section stated that the current brief was not new and that a pad would be added under the brief, and it was marked as resolved. However, there was no documented investigation into why the briefs were leaking or what intervention would prevent recurrence. During an interview, the resident reported ongoing feelings that staff were not responsive to their grievances. In a separate interview, the NHA, who served as Grievance Officer, acknowledged that the incontinence brief concern was not addressed when first reported and that the second grievance was not investigated to ensure an effective resolution for the resident.
Verbal Altercation and Disrespectful Conduct by Activity Staff Toward a Resident
Penalty
Summary
Facility staff failed to protect a resident from verbal abuse and to ensure the resident was treated with respect. During a scheduled smoke break in the courtyard, an activity assistant asked a group of residents if they wanted to listen to music. Although the majority of residents reportedly declined, the activity assistant played music anyway. The resident reported that the music selections were derogatory, inappropriate for public listening, and extremely loud, making it difficult for residents to hear one another. This led to escalating verbal exchanges between the resident and the activity assistant. According to the investigation statements, the interaction progressed into a verbal altercation involving yelling and cursing between the resident and the activity assistant until a supervisor arrived and escorted the staff member from the courtyard and out of the facility for the remainder of the day. The Recreation Program Director reported that the resident had previously complained about the music played by this same activity assistant, and that the activity assistant had also approached him about these prior conflicts. Review of the activity assistant’s employee file showed disciplinary action less than three weeks earlier for negative interactions with a resident, in which a resident was singled out and became upset. Surveyors substantiated abuse based on these findings.
Failure to Prevent Misappropriation and Ensure Proper Destruction of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ medications from misappropriation and to ensure proper controlled substance handling and documentation. A facility-reported incident described that the former Unit A manager (an RN) removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a second licensed nurse witness the destruction. The RN then left work early without notifying the nurse responsible for that medication cart. When the assigned nurse later attempted to appropriately waste medications from the cart, she discovered the narcotics were already gone. She contacted another RN, who located the Controlled Dangerous Substance Destruction Report on the former unit manager’s desk, bearing signatures and initials of that RN and another staff member. When the other staff member was interviewed, he stated he was only aware of his own medications being wasted and not the additional two narcotics listed on the form. During the survey, narcotic logbooks on Unit A were reviewed and showed multiple days with missing entries (“holes”) in the logs. The current Unit A manager explained that the facility’s process required two licensed nurses to be present for the entire destruction process, from gathering the medications through signing paperwork and destroying the drugs. The DON acknowledged the prior incident involving the former unit manager and stated that the facility’s investigation could not determine which residents’ medications had been destroyed, although she noted that pharmacy could have been contacted using prescription numbers to obtain that information. Review of narcotic logs showed that some medications were documented as sent home with residents and others as destroyed, which the DON said was based on physician orders. When asked, the DON reported that the facility did not go back to verify whether narcotics were actually sent home or destroyed on Unit A during the former unit manager’s tenure and confirmed that the only step taken to determine whether other residents were affected was to verify that all medications were signed off in the records.
Failure to Timely Report Abuse Allegations and Misappropriation of Medication
Penalty
Summary
The deficiency involves the facility’s failure to timely report allegations of abuse and misappropriation of resident property to the state agency (SA) within required timeframes, and incomplete documentation of when and to whom the allegations were reported. For one resident, documentation showed a care plan meeting note initiated by a unit manager on one date was incomplete, and a late-entry care plan note by the Social Services Director (SSD) indicated the care plan meeting occurred earlier that same day. The facility’s investigation file for this incident documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at 4:00 PM, but failed to document to whom it was reported. The final investigation report indicated the allegation was reported by a family member during a care plan meeting. The SSD’s written statement did not include the date and time she was told of the allegation, nor when and to whom she reported it. Email confirmation showed the allegation was reported to the SA at 5:55 PM that day. In interview, the ADON stated she documented the date and time she became aware of the allegation on the initial report form and acknowledged she should have documented the date and time the SSD was told of the allegation but did not. The SSD reported in interview that the care plan meeting occurred at 2:30 PM, lasted about 45 minutes, and that she reported the allegation to the ADON between 3:19 PM and 3:30 PM. A second deficiency involved the facility’s failure to timely report a misappropriation of resident medication, which is classified as a form of abuse. The facility-reported incident showed that staff member #4 made the facility aware of the concern on one date, but the SA was not notified until eight business days later at 6:00 PM. Initially, during interview, the DON stated this was considered an unusual circumstance; however, after surveyor review and interviews, the incident was classified as misappropriation of resident medication. The survey team requested email confirmations of submissions to verify reporting timeframes and reviewed concerns about reporting timeframes throughout the survey and again during exit.
Failure to Thoroughly Investigate and Document Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations and maintain complete written records for abuse, neglect, and misappropriation allegations. For one resident with no cognitive impairment, chronic pain syndrome, and a documented preference for choosing between a shower or bed bath, the record did not show that staff determined or documented the resident’s bathing preference or frequency. When this resident later reported neglect concerns about pain medication not being given for 24 hours, not receiving daily showers as preferred, and experiencing trauma triggers related to stress and being in a nursing home, the facility’s investigation file lacked key elements. The initial report did not identify to whom the concerns were reported, and the final report did not include a resident statement, interviews with other residents about showers or trauma care, or staff statements. A census sheet used as part of the investigation had check marks and a note about residents having no concerns with pain medications but lacked dates, times, and the name or signature of the interviewer. There was no evidence that staff investigated why the resident was not receiving daily showers, why the resident’s pain was not controlled, or how trauma triggers had not been identified during trauma screening. For another resident with a history of stroke and mild cognitive impairment, the facility failed to fully document and investigate an allegation of physical abuse by staff. The resident’s physician documented a need for PT and OT, and care plan meeting notes were entered by the unit manager and social services director on different times and as a late entry. The initial abuse report documented that the resident accused two male therapists of kicking the resident in the chest and stomach, and that staff became aware of the allegation at a specific time, but did not state to whom it was reported. The final investigation report stated that a family member reported the allegation during a care plan meeting and that the resident said two staff members kicked the resident in the stomach on a prior evening. The abuse was deemed unsubstantiated because the alleged perpetrators were not identified and the resident could not clearly describe the incident, and it was noted there was only one male therapist in the facility. The SSD’s written statement did not include the date and time she was told of the allegation or when and to whom she reported it. Although statements were obtained from two male staff who cared for the resident that evening and from the male therapist, the facility did not obtain statements from other staff who worked that evening/night. In a separate incident involving potential misappropriation of narcotics, the facility failed to complete a thorough investigation and maintain adequate documentation. The initial information provided to surveyors consisted only of the initial report to the state agency and the Board of Nursing regarding an RN who had been a unit manager. According to these documents, the RN removed two sheets of oxycodone from a medication cart and destroyed them without following required procedures, including having a witness present. The DON stated that they were unable to determine whose medications were destroyed, although a call to the pharmacy with the prescription number could have clarified this. Review of narcotic logs showed that narcotics were sometimes documented as sent home with residents at discharge and sometimes as destroyed. The DON acknowledged that, during the investigation, they did not verify whether narcotics documented as sent home or destroyed on that unit during the RN’s tenure were accurate, and that their only verification was that all medications were signed off. No additional investigative information was provided to surveyors before exit.
Failure to Maintain Two-Nurse Narcotic Count Verification Between Shifts
Penalty
Summary
Facility staff failed to ensure that end-of-shift narcotic count verifications were consistently completed and signed by two nurses for one of two medication carts on the A wing. Review of the A wing narcotic logbooks on 1/7/26, prompted by a prior facility report from August 2025 regarding alleged improper wasting of narcotics by a former unit manager without a witness, showed multiple days between August 2025 and December 2025 where two-nurse verification at shift change was not documented. The A unit manager stated that two nurses are supposed to sign each shift and that staff working a double shift are to complete the narcotic count with the shift supervisor. She was informed of multiple gaps in the narcotic log, and copies of the logs from August through December were requested. The DON reported that her practice was to instruct staff working a double shift to sign their initials for both shifts, which she suggested could explain missing signatures. However, comparison of staff schedules for selected time frames with the narcotic logs and corresponding signatures, conducted with the DON on 1/8/26, revealed that staff still failed to consistently sign the narcotic log between shifts even when working double shifts. Review of the facility’s Controlled Substance Administration and Accountability policy, last revised 3/2023, showed that the controlled drug record is intended to document both narcotic disposition and patient administration, and that the charge nurse or designee is to conduct a daily visual audit of controlled substance documentation with spot checks for proper destruction documentation and physician orders for removed medications. Despite these policy requirements, the narcotic log shift-to-shift verification process was not maintained, as noted throughout the survey and again at exit on 1/9/26.
Unattended Medication Cart with Unsecured Medications and Needles Near Mobile Residents
Penalty
Summary
Facility staff failed to keep medications and related supplies secured from residents when a medication cart was left unattended and accessible near the C/D unit nursing station. During a tour at 4:20 PM, a surveyor observed a medication cart pushed up against the nursing station with 2 insulin syringes, 2 hypodermic needles, and a Budesonide steroid inhaler on top. A ward clerk was seated at the desk and the C/D unit manager was in her office, but neither was assigned to or in charge of the medication cart. The Nurse Practice Educator (NPE) arrived shortly thereafter, independently observed the same unsecured items on the cart, and began looking for the nurse responsible for the cart. The NPE was informed by staff at the nursing desk that the nurse assigned to the cart was in the bathroom. Moments later, a staff member exited a bathroom across from the nursing station and returned to the unattended medication cart, and it was verified that this was her cart and that she was an RN who had previously worked at the facility. During this time, two independently mobile residents were observed on the opposite side of the nursing station, in an area where they would not be visible to staff if they approached the cart. Review of the medical record for one of these residents showed a diagnosis of Alzheimer's disease and a care plan for eating and chewing inanimate objects. The unsecured medications and administration instruments on the unattended cart in the vicinity of these vulnerable residents were reported to the DON and discussed again with the facility at exit.
Failure to Provide Three Years of Survey Results for Public Review
Penalty
Summary
The facility failed to make the last three years of survey results available for residents, family members, and visitors to review. On 01/07/2026 at 12:18 PM, surveyors reviewed the survey binder located on a table in the front lobby and found that it did not contain the required three years of survey results. During an interview on 01/07/2026 at 12:20 PM, the Nursing Home Administrator stated that he had reviewed the binder and that the facility’s standard was to have only one year of survey results available in the binder, confirming that the facility was not maintaining three years of survey results for public review as required.
Failure to Provide Required Transfer Documentation to Hospital
Penalty
Summary
The facility failed to ensure that required information was sent to the hospital when a resident was transferred. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other required information were sent with the resident. Interviews with facility staff, including the DON and hospital liaison, confirmed that the transfer occurred without the necessary paperwork or belongings being provided to the hospital. The hospital social workers also stated that they did not receive any paperwork or a bed hold notice for the resident upon transfer. Further review revealed that the facility's social worker was not involved in the discharge process and did not attempt to find alternative placement for the resident. The DON made the decision to send the resident back to the hospital due to behavioral concerns, but the resident had not been assessed by facility psychiatric services or a physician prior to transfer. The facility hospital liaison communicated with the hospital social worker about the transfer, but did not provide the required documentation. The medical director was not involved in the decision to transfer the resident.
Failure to Provide Timely Discharge Notification and Required Documentation
Penalty
Summary
The facility failed to provide timely notification of discharge to a resident, their representative, and the ombudsman prior to or during the resident's transfer back to the hospital. Medical record review showed no documentation that the required discharge notice or care plan goals were sent to the hospital at the time of transfer. Additionally, there was no evidence that the education provided included a review of the specific information required to be sent to the receiving facility. The resident was transferred due to behavioral issues, including wandering, aggression, and combativeness, but had not been assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff and hospital personnel confirmed that the resident was sent back to the hospital without the necessary paperwork, belongings, or a bed hold notice. The DON made the decision to transfer the resident and communicated with the hospital, but the hospital social workers reported not receiving any documentation or notification of appeal rights. The facility hospital liaison and medical director were not directly involved in the decision or the transfer process, and the required notifications and documentation were not provided as mandated.
Failure to Provide Required Documentation and Information During Resident Transfer
Penalty
Summary
The facility failed to provide required documentation and information to a resident or their responsible party prior to transferring the resident to the hospital. Medical record review showed that the resident was admitted to the facility and later transferred to the hospital, but there was no documentation indicating that the resident's care plan goals or other necessary information were sent to the hospital at the time of transfer. Additionally, there was no evidence that the resident or their responsible party received education or review of the specific information required to be sent to the receiving facility. The resident's belongings were also not sent with them, and no bed hold notice was provided. Interviews with facility staff, including the DON, hospital liaison, and medical director, revealed that the decision to transfer the resident was made by the DON due to behavioral concerns, but the resident had not been assessed by a facility physician or psychiatric services prior to transfer. Communication between facility staff and the hospital was limited to verbal notification, and the hospital social workers confirmed that no paperwork or belongings accompanied the resident. The medical director stated they had no input in the transfer decision.
Failure to Provide Bed Hold Notice and Required Transfer Documentation
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident or the resident’s representative prior to the resident’s transfer to the hospital. Medical record review showed no documentation that a bed hold notice was given, nor was there evidence that the required care plan goals or specific transfer information were sent to the hospital at the time of transfer. Interviews with facility staff, including the DON and hospital liaison, confirmed that the resident was transferred due to behavioral issues without being seen by facility psychiatric services or a facility physician, and that no paperwork or belongings accompanied the resident to the hospital. Further interviews with hospital social workers revealed that the hospital did not receive any paperwork or a bed hold notice for the resident upon transfer. The DON acknowledged making the decision to send the resident back to the hospital and confirmed that the resident was not under involuntary discharge. The facility hospital liaison and medical director also confirmed a lack of involvement in the transfer decision and absence of required documentation, resulting in the deficiency.
Failure to Issue Involuntary Discharge Notice and Provide Required Transfer Documentation
Penalty
Summary
The facility failed to issue an involuntary discharge notice to a resident prior to transferring the resident to the hospital, which resulted in the resident not being informed of their legal rights as required for residents in long-term care. The resident, who had been admitted to the facility and later transferred to the hospital due to behaviors such as wandering, aggression, and combativeness, did not have documentation in their medical record indicating that care plan goals or required transfer information were sent to the hospital. Additionally, there was no evidence that the resident was assessed by facility psychiatric services or a facility physician prior to the transfer. Interviews with facility staff, including the DON and hospital liaison, revealed that the decision to send the resident back to the hospital was made by the DON, and the hospital was informed that the resident would not be returning to the facility. The hospital social workers confirmed that no paperwork, belongings, or bed hold notice accompanied the resident upon transfer, and the facility medical director stated they had no input in the decision. The lack of proper documentation and communication regarding the resident's transfer and discharge process led to the deficiency.
Failure to Provide Warm Palatable Food to Residents
Penalty
Summary
The facility staff failed to implement measures to provide warm palatable food to residents, as evidenced by observations and interviews. A complaint was reviewed regarding cold meals, and during an interview, a resident confirmed that their food was sometimes not warm. A test tray was requested during lunch service, and it was found that the food was only slightly warm. The tray lacked a heated base or pellet, which are typically used to maintain food temperature. Additionally, trays were observed being delivered on an open rack without any means to keep the food warm. Further interviews revealed that the facility had insufficient heated pellets and no pellet warmer, which contributed to the issue. The Food Service Manager (FSM) was unaware of how long it had been since heated pellets were used and did not know if a pellet warmer had been ordered. Another test tray during lunch service showed food temperatures well below acceptable levels, with a chicken thigh at 85°F, corn at 98°F, and roasted potatoes at 82°F. These findings were reviewed with the Administrator and Director of Nursing.
Inaccurate MDS Assessments for Side Rails and Functional Status
Penalty
Summary
The facility failed to complete accurate assessments for residents regarding the use of side rails and the functional use of extremities on the quarterly and annual Minimum Data Set (MDS). For Resident #29, the MDS inaccurately coded the use of bed rails as 'not used' across multiple assessments, despite observations and documentation indicating the presence of 1/2 size side rails. Additionally, the MDS inaccurately reported 'no impairment' in the resident's extremities, contradicting nursing documentation and observations. MDS staff acknowledged that information is primarily gathered electronically, with occasional resident observations to confirm electronic records. For Resident #5, a physician order for 1/4 side rails as enablers was documented, yet the MDS inaccurately coded 'not used' for bed rails in several assessments. Similarly, Resident #30 had a family consent for side rails, and observations confirmed their presence, but the MDS inaccurately reported 'not used' for side rails in both annual and quarterly assessments. These discrepancies were discussed with the facility's Director of Nursing, highlighting a pattern of inaccurate MDS assessments related to side rail usage and functional status.
Improper PPE Removal During COVID-19 Outbreak
Penalty
Summary
Facility staff failed to adhere to the Centers for Disease Control's guidelines for removing personal protective equipment (PPE) during a COVID-19 outbreak. Observations revealed that a Geriatric Nursing Assistant (GNA) exited a resident's room wearing a gown, gloves, mask, and shield, and removed the gown and gloves in the hallway instead of inside the room. The GNA did not sanitize his hands after removing the PPE and was observed touching his mask and face shield multiple times. Additionally, the GNA took two food trays into a resident's room simultaneously without changing gloves or gown between residents, which is against infection control practices. Interviews with the Unit Manager and Infection Control Preventionist highlighted a lack of recent PPE training and monitoring of staff compliance with infection control protocols. The Unit Manager acknowledged that staff should have intervened when witnessing improper PPE removal. The Infection Control Preventionist admitted that the last PPE training was conducted three months prior and that no additional training had been provided since the COVID-19 outbreak began. The facility's infection control practices were not aligned with CDC guidelines, as PPE was not consistently removed and discarded before leaving the resident's room.
Cluttered Hallways Compromise Safety in Nursing Units
Penalty
Summary
The facility failed to maintain a safe environment for residents across three of its four nursing units, specifically Units A, B, and D. On Unit A, the hallway was cluttered with various items including wheelchairs, dining room chairs, isolation carts, and even a bedpan with a toilet plunger, leaving less than three feet of maneuverable space. This clutter was due to maintenance activities that required moving furniture from rooms into the hallway. The Unit Manager was unaware of the clutter and had not addressed it, raising concerns about emergency evacuation procedures. On Unit B, the hallway was similarly obstructed with Geri chairs, wheelchairs, medication carts, and breakfast carts, making handrails inaccessible and the hallway crowded. The DON was informed of these issues, which persisted over several days. On Unit D, the hallway was obstructed by reclining chairs, wheelchairs, and dining room chairs, reportedly due to insufficient space in resident rooms for GNAs to provide morning care. Despite being informed of the safety concerns, the clutter remained over multiple days, indicating a systemic issue with maintaining clear and accessible hallways.
Failure to Honor Resident's Advance Directive
Penalty
Summary
The facility failed to adhere to the wishes of a resident as outlined in their advance directive, which specified that all measures should be taken to extend their life, including the use of a gastrostomy tube for nutrition if necessary. Despite this, the MOLST form on file indicated that artificially administered nutrition should not be given, a decision that was influenced by the resident's healthcare agent who opposed the use of a feeding tube. This discrepancy between the advance directive and the MOLST form was not addressed by the facility, leading to a failure in honoring the resident's documented preferences. The resident, who had multiple comorbidities including dementia and dysphagia, experienced repeated hospitalizations due to aspiration pneumonia and dehydration. During these hospitalizations, evaluations indicated a high risk of aspiration and recommended that the resident be NPO pending further assessments. Despite these recommendations and the resident's significant weight loss, the facility did not implement the use of a feeding tube as per the advance directive, due to the healthcare agent's opposition. Interviews with facility staff, including the nurse practitioner and social worker, revealed that there was an assumption that the healthcare agent's decisions overrode the advance directive. The facility's Director of Nursing acknowledged the issue and indicated that they were contacting the healthcare agent for further consultation. However, the failure to align the MOLST with the advance directive and to follow the resident's stated wishes constituted a deficiency in the facility's care practices.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility staff failed to report an allegation of abuse in a timely manner to the State Agency. This deficiency was identified during a complaint survey involving a resident who reported being hit on the cheeks by a male and female staff member. The incident occurred at approximately 3:00 AM and was reported to a Licensed Practical Nurse at 5:30 PM on the same day. However, the facility did not report the allegation to the state agency until 10:30 PM, which was 5 hours after the staff became aware of the incident, instead of the required 2-hour timeframe. The Director of Nursing was informed of these findings during the survey.
Incomplete Investigation of Alleged Resident Abuse
Penalty
Summary
The facility staff failed to thoroughly investigate an allegation of resident abuse involving a resident who was reportedly struck on the hand by a receptionist. The incident was reported by a family member, who also mentioned that the resident's roommate confirmed the event. The facility's investigation included an assessment of the resident and statements from staff, but it was unable to conclude whether the alleged abuse occurred. However, the investigation was incomplete as it did not include interviews with the resident's roommate or other residents who might have had relevant information. During an interview, the Assistant Director of Nursing, who was responsible for the investigation, admitted to not remembering who was interviewed and failed to provide evidence of interviews with the roommate or other residents. Initially, she claimed the roommate was not alert, then changed her statement to say the roommate was alert but not oriented. The investigation file lacked documentation of any resident interviews, highlighting a significant gap in the investigation process. The Director of Nursing was informed of these findings.
Failure to Reassess Residents' Elopement Risk
Penalty
Summary
The facility staff failed to properly assess two residents after significant changes in their conditions, leading to unnecessary monitoring with elopement deterrent devices. Resident #22, who had previously eloped from the facility, was assessed multiple times in 2024 and found to be a low elopement risk. Despite this, the resident continued to be monitored with a wanderguard, a decision attributed to the Director of Nursing and Unit Managers. Interviews with facility staff confirmed that the resident was no longer considered an elopement risk, yet the monitoring device remained in use until it was eventually removed. Similarly, resident #28, who also had a history of elopement, was not reassessed for elopement risk after the initial incident in 2022. The only subsequent assessment in 2023 indicated a low risk, yet the resident continued to be monitored with a wanderguard. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed a lack of clarity on the necessity of the monitoring device, highlighting a failure to reassess the resident's condition appropriately.
Failure to Update G-Tube Care Plan After Change in Status
Penalty
Summary
The facility failed to update a resident's care plan following a change in status, specifically concerning the care of the resident's g-tube. The resident experienced multiple incidents where the g-tube became dislodged, necessitating hospital transfers for replacement on several occasions, including in August 2022, September 2023, July 2024, and October 2024. Despite these incidents, the facility did not update the care plan with new interventions after the dislodgements in July and October 2024, with the last update occurring in September 2023. Interviews with facility staff, including the C/D Unit Manager and the Nurse Educator, confirmed that the responsibility for updating care plans after a change in status lies with the unit managers. However, the C/D Unit Manager did not update the care plan following the incidents in 2024. The Director of Nursing was informed of this failure by the surveyor, highlighting a lapse in the facility's protocol for maintaining current and effective care plans for residents experiencing changes in their medical status.
Failure to Document ADL Care for Dependent Residents
Penalty
Summary
The facility failed to document care provided to residents who were dependent on staff for activities of daily living (ADL), specifically related to bowel and bladder care. For Resident #11, who was coded as requiring extensive assistance and frequently incontinent, there were multiple days where staff did not document the provision of bowel and bladder care. During a specific period, care was documented only twice out of a potential ten times. This lack of documentation was confirmed through interviews with facility staff, who acknowledged that ADL records should not have any blanks. Similarly, for Resident #16, who was dependent on staff for ADL care due to multiple comorbidities and was frequently incontinent, there was a lack of documentation for incontinence care over several shifts. The records showed no documentation of care provided during specific evening and night shifts, and no bowel movements were recorded over 11 shifts. Interviews with staff confirmed that documentation should occur every shift, highlighting a consistent failure in maintaining accurate records of care provided.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to develop and implement a process to ensure that residents with a history of trauma received appropriate trauma-informed care. This deficiency was identified during a review of the medical records and interviews, specifically for one resident out of three reviewed for trauma-informed care. The medical record review revealed that the resident was admitted to the facility without an assessment or care plan to ensure trauma-informed care was provided. An interview with a social worker indicated that trauma-informed care assessments were conducted on admission and annually, but at the time of the resident's admission, the facility was not administering these assessments. It was noted that a trauma-informed care assessment was eventually completed, and a care plan was implemented after a complaint investigation.
Failure to Properly Assess and Reassess Bed Rail Use
Penalty
Summary
The facility failed to properly assess and reassess residents for the use of bed rails, leading to deficiencies in care. For Resident #26, there was a lack of documentation regarding attempted interventions or alternatives to bed rails, despite a significant change in the resident's functional status. The resident had a history of falls and injuries, including a fractured nasal bone, yet the facility did not conduct a reassessment after these incidents. Observations showed the resident using half side rails, contrary to the documented use of quarter side rails, and there was no follow-up assessment after the noted decrease in the resident's extremity functionality. For Resident #3, the facility also failed to adhere to the assessment recommendations. Despite an assessment on 3/27/24 advising against the use of bed rails, the resident continued to use them, resulting in a discoloration on the forehead from resting against the rail. Interviews with staff confirmed the continued use of bed rails to prevent falls, but there was no evidence of reassessment or consideration of alternative safety measures following the change in the resident's condition.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the staff's failure to administer medications in accordance with professional standards. This deficiency was identified for one resident who was reviewed for medication administration. The resident's medication administration audit for November 2023 revealed that medications were consistently administered late, outside the 1-hour time frame specified. Specifically, Tylenol, Prednisone, Metoprolol Tartrate, and Finasteride were all administered outside the prescribed time frames on multiple occasions. These findings were confirmed through observation, record review, and interviews, and were discussed with the Director of Nursing.
Failure to Notify Physician of Lab Results
Penalty
Summary
The facility failed to ensure that a physician was notified of lab results for a resident with multiple comorbidities, including uncomplicated diabetes and anemia. The resident was seen by a Nurse Practitioner (NP) who ordered a repeat CBC due to leukocytosis noted in previous labs. However, the lab report from the ordered test was not available in the resident's medical record, and there was no documentation indicating that any physician was notified of the results. The lab report contained several flagged high and low results, which were not addressed until 13 days later when the NP saw the resident again. The Medical Director confirmed that the lab results were reviewed only during the subsequent visit by the NP, and a repeat CBC was ordered at that time. The surveyor noted that the lab report was not on the chart and had to be printed by the Director of Nursing (DON) upon request. This delay in reviewing and addressing the lab results highlights a deficiency in the facility's process for ensuring timely notification and follow-up on lab results.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 355 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Laplata
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green Acres Nursing And Rehab | 1.6 mi | ★★★★★ | 17 | 0 |
| Restore Health Rehabilitation Center | 4.2 mi | ★★★★★ | 4 | 0 |
| Waldorf Center | 5.2 mi | ★★★★★ | 27 | 0 |
| Charlotte Hall Veterans Home | 12.1 mi | ★★★★★ | 0 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 13 mi | ★★★★★ | 35 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.