Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Multi Medical Center Llc during CMS and state inspections, most recent first.
Medication administration errors exceeded the allowed limit when multiple observed doses were incorrect, omitted, or documented as given without being observed. An LPN gave a resident Zyrtec after the ordered course had expired and failed to administer several ordered meds while documenting some as administered; another nurse gave a whole Venlafaxine tablet instead of a half tablet and could not account for several other ordered meds that were not observed being prepared or given.
Failure to Notify Ombudsman of Hospital Transfers: A resident had two hospitalizations and returns to the facility, but the resident was not included on the facility’s original list of residents sent to the Ombudsman regarding transfers and discharges. During survey review, the NHA confirmed the omission and later provided a revised list that included the resident; the reason for the omission was unclear.
A facility failed to ensure dependent residents received needed ADL care, including oral care, timely incontinence care, and scheduled showers, and failed to document some of the care provided. One resident had visible plaque on the teeth and reported not receiving help with oral care despite an order for oral care twice daily and dependence for that task. Another resident’s family reported delayed or absent response to call bells for incontinence care, with charting showing care only once per shift. A third resident, dependent for toileting hygiene and bathing, had missing shower documentation and multiple missed shower dates, and the DON could not verify that undocumented incontinence care had been provided.
Failure to provide ordered splinting for a resident with right wrist and elbow contractures. The resident was observed with the right arm and hand contracted without a device, and the resident indicated a splint was not usually placed in the hand. Records showed an order for a right carrot splint to be worn overnight and a care plan directing staff to assist with supportive devices, yet a later observation again found no splint in place. An RN said she did not know whether the resident usually wore a splint.
Failure to supervise allowed a resident with a wanderguard to elope through the front door after following an employee who disabled the alarm to leave. Staff last saw the resident during med pass and did not realize the resident was missing until police returned the resident from an adjacent parking lot. The resident had an elopement/wandering care plan element that included wanderguard checks, but no documentation was found showing those checks were being performed.
Medication Storage Not Kept in Locked Compartments: An LPN administered some ordered meds to a resident but did not give two scheduled topical meds, and one cream was later found on the resident’s bedside table. The LPN said she confused the meds and could not find the missing gel in the cart or bedside drawers, while the DON confirmed meds should not be stored at the bedside. The facility policy required drugs and biologicals to be stored in locked compartments.
Meals were not served according to the posted menu, and a resident with a reported milk allergy did not receive an alternate breakfast or beverage. The resident said staff often failed to bring coffee or the preferred juice, and meal tickets and tray observations showed the breakfast items on the menu were not provided on two observed occasions. The KM confirmed the menu should match the tray and acknowledged no alternate was entered for the resident despite available milk substitutes.
Improper food storage and inadequate nourishment refrigerator temperature were identified in the kitchen and on the units. An open box of sausage patties was found in the freezer with the plastic bag pulled back and the sausage exposed to the environment, and a nourishment refrigerator on the 2nd floor was found at 52 degrees.
A resident admitted for rehab after a left hemiarthroplasty had incomplete bathing documentation in the EHR and shower log binder. Staff found only one bed bath entry in the e-Kardex, no active bathing or shower restriction orders at first review, and no binder documentation showing the resident received scheduled showers or bed baths. RN and DON confirmed the documentation gaps, and later paper sheets and a shower restriction order were added.
Two residents receiving oxygen therapy were observed with humidifier bottles and oxygen tubing that were not dated to show when they were placed in use. Staff confirmed the missing dates on the oxygen equipment during the observations.
A resident who was totally dependent for all care and bed mobility, with contractures to the RUE and right-sided paralysis, had a call bell found out of reach and entangled on the headboard during repeated observations. Surveyors also found 1 of 3 shower bays in a unit shower room without an adequately long call device activation cord, showing that call devices were not accessible in the resident room and bathing area.
Incomplete daily nurse staffing information was posted on multiple resident care units. Surveyors observed that staffing boards on several units had no staffing ratios posted, were not filled out, or listed only LPNs and RNs without including GNAs. Follow-up observation showed the same issues remained on multiple units, and the DON was informed during the survey.
The facility failed to ensure meals were palatable and served at appropriate temperatures, affecting all residents. Several residents reported consistently receiving cold meals, such as scrambled eggs, and cold beverages not served at appropriate temperatures. The CDM acknowledged issues with timely delivery by nursing staff and provided only monthly tray testing results, despite ongoing complaints for at least three months.
A resident dependent on ADL care was observed with excessive mucous around their tracheostomy dressing and neck on multiple occasions. Despite the presence of an LPN, the resident remained soiled, as the LPN deferred suctioning to the Respiratory Therapist. The DON confirmed that nurses are trained to perform suctioning, yet the resident's condition was not promptly addressed.
A survey revealed that residents were unaware they could hold resident council meetings without facility staff present. During a meeting attended by fourteen residents, including the Resident Council President via iPad, it was confirmed that they did not know about this right. An Activities Assistant also expressed unawareness of this possibility, leading to a deficiency in respecting residents' rights to organize independently.
Residents were not informed about the identity or contact information of the facility Ombudsman, violating their rights to receive notices in a format and language they understand. During a resident council meeting, it was revealed that none of the residents knew the Ombudsman's name or how to contact them. Guest Services Director confirmed the residents' lack of awareness.
A facility staff member inaccurately coded a resident's MDS assessment, indicating the use of a trunk restraint when none was used. The error was confirmed by the MDS Coordinator after the resident denied using such a restraint.
A resident's medication administration was inaccurately documented by an LPN, who signed off that Metoprolol was given despite the resident's g-tube being clogged and orders prohibiting oral administration. The resident was later hospitalized for g-tube replacement.
A resident who was dependent on assistance for ADL care reported not receiving a shower since admission. Facility documentation lacked records of showers being provided or refused. The resident stated they were not offered a shower prior to the previous day, indicating a failure in care provision and documentation.
A resident received blood pressure medication outside the prescribed parameters on multiple occasions. The medication was supposed to be held if the systolic BP was less than 110 and heart rate less than 60, but it was administered despite readings below these thresholds. Interviews revealed that geriatric nursing aides are responsible for obtaining BP readings, and LPNs are to hold medication if parameters are not met, but this process was not followed.
A facility was found to have a medication error rate of 6.67% due to an LPN's failure to administer an antiviral medication on time and incorrect documentation of a Fortified Nutritional Shake that a resident refused. The DON acknowledged the errors and noted the availability of a Pyxis system for medication dispensing.
The facility staff failed to discard expired medications in one of the medication storage rooms. Expired items, including intravenous bags and vitamins, were found during a survey. Interviews revealed unclear responsibilities between the unit clerk and central supply personnel regarding the management of expired medications, leading to the oversight.
The facility failed to ensure that GNAs received annual dementia training, as there was no documentation confirming completion for four GNAs. The educator, who took over in July, could not verify the training due to a transition to electronic records. The administrator acknowledged incomplete education files due to previous filing issues, identified during a quality assessment meeting.
Medication Administration Error Rate Exceeded Allowed Limit
Penalty
Summary
Medication administration errors exceeded the allowed rate when 11 of 41 medications observed during a facility task were found to be in error, resulting in an error rate of 26.83%. During one observation, an LPN administered Zyrtec to a resident even though the order was for a 7-day course that had already expired, and the nurse later stated the resident should not have received it and that a new order should have been obtained. During another observation, an LPN prepared and administered some ordered medications for a resident but failed to administer several others that were ordered, including Metoprolol, Menthol gel, Skin Prep spray, and Diclofenac gel. The MAR showed documentation that some of these medications had been administered even though the nurse stated Metoprolol had been held because of low blood pressure and heart rate, had not notified the provider, and admitted the medication was signed off in error. The nurse also stated she confused Menthol gel with Diclofenac gel and could not locate the Menthol gel in the building, yet the MAR indicated it had been given. In a separate observation, a CMA administered medications to another resident but gave a whole tablet of Venlafaxine when the order was for one-half tablet. The surveyor also did not observe administration of Jardiance, Miralax, Salonpas patch, eye drops, or sodium fluoride paste even though some of these were documented as given. During interview, the CMA stated the Venlafaxine dose was wrong, said the resident had received Jardiance despite being unable to produce the medication, and acknowledged that some medications were signed off as administered even though they were not observed being prepared or given.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure that the Ombudsman was notified of resident transfers to the hospital for Resident #104. Record review showed that the resident was transferred to the hospital for emergent care on 12/03/2025, admitted, and later returned to the facility, and was transferred again to the hospital and returned on another date. During surveyor review on 02/26/2026, the Nursing Home Administrator was asked to provide documentation of notification to the Ombudsman regarding resident transfers and discharges. The facility's list of residents sent to the Ombudsman did not include Resident #104, even though the resident had two hospitalizations in December 2025. A revised list was later provided that included Resident #104, and the Nursing Home Administrator confirmed it was sent to the Ombudsman; the reason for the omission from the original notification list was unclear.
Failure to Provide and Document Required ADL Care
Penalty
Summary
The facility failed to ensure dependent residents received needed ADL care, including oral care, incontinence care, and scheduled showers, and failed to document some of that care. For one resident, the surveyor observed a brownish plaque-like substance on the upper and lower teeth during an interview, and the resident stated that help with oral care was not being provided and that the teeth needed brushing. The medical record showed a physician order for oral care twice daily and an MDS assessment coding the resident as dependent for oral care. For another resident, the family member reported being present around the clock during a 5-day stay and stated that the resident repeatedly used the call bell for incontinence care, but staff were slow to respond, taking 10 to 30 minutes or not coming at all. The family member said they had to go to the nurse’s station to request assistance. The medical record showed incontinence care was documented only once per shift, and the DON confirmed that was how it was charted. For a third resident, complaint review and record review showed the resident was dependent for toileting hygiene and showering. The documentation survey report listed shower days as Tuesday and Friday, but the record contained only three shower sheets over several months, and no corresponding shower sheets were found for numerous scheduled shower dates. The DON stated that the resident should have received showers per the Kardex and acknowledged that the documentation showed missed showers and missing shower sheets. The record also showed multiple shifts with no documentation of incontinence care, and the DON was unable to confirm that care had been provided on those undocumented shifts.
Failure to Provide Ordered Splinting for Hand Contracture
Penalty
Summary
The facility failed to provide adequate care to prevent complications from hand contractures for one resident with contractures of the right wrist and right elbow. On 02/24/2026, the surveyor observed the resident’s right arm and hand contracted without a device in place, and the resident indicated that a splint or other device was not usually placed in the right hand. The report defines a carrot splint as a soft cone-shaped device used to gently open and position severe hand contractures and prevent finger-to-palm skin breakdown, moisture buildup, and potential nail punctures. Record review showed a physician’s order for a right carrot splint to be applied at 12 midnight and left on for 8 hours as tolerated, with frequent adjustment required. The care plan identified an alteration in musculoskeletal status related to contractures and directed staff to assist the resident with supportive devices, including carrot splints. Despite this, an additional observation on 02/26/2026 found no splint on the resident’s right upper extremity, and the resident again indicated there was no device in the hand overnight. During interview, an RN stated she did not know whether the resident usually wore a splint and would request one. The DOR later brought a new carrot splint and placed it into the resident’s right hand, and the DON was informed of the findings.
Failure to Supervise Allowed Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident when Resident #27 eloped from the facility through the front door. On August 2, 2025, at 8:35 PM, the resident followed Employee #36 as that employee was leaving for the day, and the employee disabled the alarm to exit the building. The resident was found by police wandering in an adjacent parking lot and was returned to the facility after the officer verified with Employee #35 that the resident lived there. Staff had last seen the resident at 8:30 PM when the resident received medication and did not know the resident was missing until police brought the resident back. At the time of the elopement, the resident had a wanderguard on the left ankle. Employee #36 stated during the facility investigation that they believed the resident was a visitor and had a brief conversation with the resident before the resident walked toward the parking lot as if going to a car. Upon return, a head-to-toe assessment found no injuries. The resident had an elopement/wandering care plan element before the incident that included checking the wanderguard for placement and function, but the surveyor could not find documentation that these checks were being performed.
Medication Storage Not Kept in Locked Compartments
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments. During a medication administration observation, an LPN prepared and administered two medications to a resident, but two other ordered topical medications were not observed being given at the scheduled time: Menthol topical analgesic external gel 4% for pain and Diclofenac sodium external gel 1% for pain. When asked about the missing Menthol gel, the LPN stated she did not give it because she did ointments after medications and did not want to mix them together, then said she had confused the name and thought it was the Diclofenac. The LPN searched the treatment cart and medication cart and stated the Menthol gel was not available there. She then went to the resident's room, where the Diclofenac was observed on the bedside table, and she was unable to locate the Menthol gel in the bedside nightstand drawers. The LPN stated the resident had two boxes that were normally kept in the room, although she also stated the medications were not supposed to be stored at the bedside. The DON later confirmed medications should not be stored at the bedside. The facility's Medication Storage policy stated all drugs and biologicals would be stored in locked compartments such as medication carts, cabinets, drawers, refrigerators, and medication rooms.
Meals Not Served Per Menu and No Alternate Provided for Allergy
Penalty
Summary
The facility failed to serve meals according to the predetermined menu and did not have a system in place to ensure alternative foods and beverages were provided for residents with allergies. Resident #6, who was admitted in June 2025 and was able to communicate needs verbally, reported that breakfast meals were deficient and that he/she often had to ask for milk and coffee even though coffee was consumed every morning. The resident also stated that staff did not ask what he/she wanted to eat, that orange juice was preferred and listed on the menu, but a different reddish drink was served instead. The resident further stated that he/she believed there was a milk allergy, though he/she described it as causing loose bowels if a whole container was consumed. Surveyor review of the Week 4 menu showed that on Tuesday breakfast was to include scrambled eggs with cheese, oatmeal cereal, cold cereal of choice, biscuit, margarine, jelly, milk, coffee or hot tea, and orange juice, and on Thursday breakfast was to include buttermilk pancakes, margarine, syrup, sausage patty, oatmeal cereal, cold cereal of choice, milk, coffee or hot tea, and orange juice. Dual observation of the resident's meal tickets and trays showed that on both breakfasts the resident did not receive the menu items listed and did not receive an alternate meal. The Kitchen Manager stated that everyone gets the regular meal unless they have a dislike or allergy and then they get the alternate, confirmed that the delivered food should match the menu, and acknowledged that there was no alternate typed in for the resident. She also stated the facility had milk alternatives such as almond milk, soy milk, and oat milk, but did not know why the resident did not receive an alternate milk.
Improper Food Storage and Inadequate Nourishment Refrigerator Temperature
Penalty
Summary
Food items were not stored in a manner that maintained the integrity of the product, and nourishment refrigerators were not maintained at the appropriate temperature. During the initial kitchen tour on 2/24/2026 at 8:10 am with Employee #39, a box of sausage patties in the freezer was found open, with the plastic bag pulled completely back and the sausage exposed to the environment. On 2/25/2026 at 2:54 pm, a temperature check of the nourishment refrigerators on the units found the 2nd floor unit refrigerator registering 52 degrees.
Incomplete Bathing Documentation and Missing Shower Orders
Penalty
Summary
The facility failed to keep complete and up to date medical records for one resident. Resident #80, who was admitted for rehabilitation after a left hemiarthroplasty, told the surveyor that they had not been showered by staff since admission. A review of the electronic health record showed only one documented bed bath in the resident’s e-Kardex on 2/21/2026, and no other documentation of showers or bed baths was found in the EHR. There were also no active medical orders in the EHR for bathing or showering services, or an order to not shower if contraindicated. A review of the unit shower/bed bath log binder showed a schedule for the resident’s room to receive bathing on Tuesdays and Fridays, but there was no documentation in the binder that the resident had received a shower or bed bath on those days since admission. RN #9 stated that showering and bathing are expected to be documented in both the shower/bed bath binder and the EHR, and confirmed that the only documentation found was the 2/21/2026 bed bath entry. The DON acknowledged concern about the lack of documentation. Later, paper shower/bed bath sheets were provided showing the resident refused a shower/bed bath on 2/25/2026, and additional sheets dated 2/10/2026 and 2/17/2026 documented bed baths and shower refusals. An email from the resident’s orthopedist office stated the office preferred patients not shower until their post-operative appointment, and an EHR order reflecting a showering restriction was entered on 2/25/2026 at 8:01 PM.
Undated oxygen tubing and humidifier bottles
Penalty
Summary
The facility failed to ensure oxygen tubing and humidifier bottles were dated to reflect appropriate change and monitoring in accordance with infection control practices for 2 residents reviewed for oxygen use. Resident #43 was observed receiving oxygen therapy with a humidifier bottle attached, but neither the bottle nor the oxygen tubing had a date indicating when they were placed in use. Resident #60 was also observed receiving oxygen therapy with oxygen tubing and a humidifier bottle attached, and these items were likewise not dated. Staff confirmed the absence of dates on both residents’ oxygen equipment during the observations.
Call Devices Not Accessible in Resident Room and Shower Area
Penalty
Summary
The facility failed to ensure residents had access to a call device system in resident bathrooms, bathing areas, and resident rooms. Surveyors observed Resident #17's call bell device out of reach on multiple occasions, with the device entangled on the headboard and later found wrapped behind the headboard before being placed near the resident's left hand by RN #13. Resident #17 was totally dependent for all care and bed mobility and had contractures to the right upper extremity and right-sided paralysis. Surveyors also observed a shower room on the [NAME] Unit with 1 of 3 shower bays lacking an adequately long call device activation cord during an observation made with the unit manager.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to post complete and accurate daily nurse staffing information on each resident care unit, including the required staffing ratios for licensed nurses and nurse aides. During surveyor observations on the Chesapeake, Evergreen, and two additional units, the staffing dry erase boards either had no staffing ratio posted, were not filled out, or listed only licensed nurses without including Geriatric Nursing Assistants (GNAs). On follow-up observation, the Chesapeake unit still had no staffing ratio posted, the Evergreen unit still had an incomplete ratio listing that excluded GNAs, and the two additional units still had no staffing ratio posted. The Director of Nursing was informed of the findings during the survey.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility staff failed to ensure that meals were palatable and served at appropriate temperatures, affecting all residents receiving meals from the facility's kitchen. During a tour of the units, several residents reported that their meals, including scrambled eggs, were consistently served cold. The certified dietary manager (CDM) acknowledged that meal carts were sent up in a timely manner, but nursing staff were not delivering the trays within 15 minutes of arrival. Additionally, the CDM stated that the hold temperature for hot food items was maintained at 140 degrees or greater, and the pellet bases/chargers had been replaced recently. A resident council meeting revealed that residents consistently experienced meals that were not warm or hot, with examples such as butter not melting on food. The surveyor observed that while the main courses were within safe temperature ranges, cold beverages like apple juice were not served at appropriate temperatures, with some readings as high as 80 degrees. The facility had been aware of residents' complaints about cold food for at least three months, but the CDM had not provided weekly tray testing results, only monthly ones, prior to the exit conference.
Failure to Maintain Dignity in Resident's Tracheostomy Care
Penalty
Summary
The facility staff failed to provide a dignified existence to a resident dependent on Activities of Daily Living (ADL) care. This deficiency was observed in one of the three dependent residents assessed during the survey. On two separate occasions, the surveyor observed the resident in bed with a significant amount of mucous overflowing around the tracheostomy dressing and on the right side of their neck. Despite the presence of a Licensed Practical Nurse (LPN) in the room, the resident remained soiled with mucous, as the LPN indicated that the Respiratory Therapist was responsible for suctioning the resident. During an interview with the Director of Nursing (DON), it was confirmed that nurses are trained to suction residents, and respiratory therapists are available on the unit to provide care. However, the resident continued to be observed in a soiled state, indicating a failure in providing timely and appropriate care.
Residents Unaware of Right to Hold Independent Meetings
Penalty
Summary
During a survey, it was found that residents participating in the resident council meetings were unaware that they could hold meetings without facility staff being present. This issue was identified during a resident council meeting attended by fourteen residents, where the surveyor inquired about the resident council process. The residents, including the Resident Council President who attended via iPad video, expressed that they did not know they could conduct meetings independently of staff presence. Additionally, an interview with an Activities Assistant revealed that they were also unaware that residents could hold meetings without staff being present. This lack of awareness among both residents and staff led to the deficiency in honoring the residents' right to organize and participate in resident/family groups independently.
Residents Unaware of Ombudsman Contact Information
Penalty
Summary
Residents were not informed about the identity or contact information of the facility Ombudsman, which is a violation of their rights to receive notices in a format and language they understand. During a resident council meeting attended by fourteen residents, it was revealed that none of the residents knew the Ombudsman's name or how to contact them. This deficiency was confirmed through an interview with Guest Services Director #24, who acknowledged that the residents were not aware of the Ombudsman. The director mentioned that meeting dates and times for the resident council are posted in case the Ombudsman wants to attend, but there was no indication that the Ombudsman had been introduced to the residents or that their contact information had been shared.
Inaccurate MDS Assessment Due to Incorrect Coding
Penalty
Summary
The facility staff failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for a resident. During an annual assessment, the staff incorrectly coded the MDS Section P 0100, indicating the use of a trunk restraint for the resident. However, upon review and observation, it was found that the resident did not use a trunk restraint, and the resident themselves denied its use. The MDS Coordinator confirmed that the MDS was coded incorrectly, leading to the inaccurate assessment.
Medication Administration Documentation Error
Penalty
Summary
The facility staff failed to meet professional standards by inaccurately documenting medication administration for a resident. The resident had physician orders for Keppra to be administered via g-tube twice daily for seizures and Metoprolol Tartrate by mouth twice daily for tachycardia. On May 31, 2023, the LPN documented that Keppra was not administered at 5 PM due to a clogged g-tube, yet later signed off that Metoprolol was administered at 9 PM. However, the Director of Nurses confirmed that the Metoprolol was not administered either by g-tube or mouth, as the resident was not to receive anything by mouth per physician order. The resident was subsequently transferred to the hospital on June 1, 2023, for g-tube replacement.
Failure to Provide Showers to Dependent Resident
Penalty
Summary
The facility staff failed to provide showers to a resident who was dependent on assistance for activities of daily living (ADL) care. This deficiency was identified when a resident, who was unable to stand independently, reported not receiving a shower since being admitted to the facility. Upon review of the facility's documentation in PointClickCare (PCC), there was no record of the resident receiving a shower, nor was there documentation indicating that the resident had refused a shower. The Director of Nursing (DON) confirmed that the documentation should have been present in the PCC system. Further investigation revealed that the facility later provided documentation indicating the resident had refused showers on specific dates. However, the resident stated they had not been offered a shower prior to the previous day and had not refused any showers. The resident was admitted to the facility on an unspecified date and should have received a shower at some point during their stay. The lack of documentation and the resident's account suggest a failure in providing necessary care and maintaining accurate records.
Failure to Administer Blood Pressure Medication as Ordered
Penalty
Summary
Facility staff failed to administer blood pressure medication as ordered by the physician for a resident. The medication, Metoprolol Succinate 25mg extended release, was prescribed to be taken every 24 hours with specific parameters to hold the dose if the systolic blood pressure was less than 110 and heart rate less than 60. However, the medication was administered on multiple occasions when the resident's blood pressure readings were below the prescribed parameters, specifically on 09/26/24, 10/04/24, 10/08/24, 10/11/24, and 10/14/24. During interviews, the Unit Manager explained that geriatric nursing aides are responsible for obtaining blood pressure readings and communicating them to the assigned nurse. The Licensed Practical Nurse stated that medication orders are reviewed, and if blood pressure readings are outside the ordered parameters, the medication should be held, and the doctor notified. Despite this process, the medication was not held as required by the physician's order, leading to the deficiency.
Medication Error Rate Exceeds 5% Due to Documentation and Administration Issues
Penalty
Summary
The facility was found to have a medication error rate greater than 5%, specifically 6.67%, during a survey. This deficiency was identified through observations and record reviews involving a resident. On the morning of November 6, a surveyor observed an LPN preparing medications for a resident, but the antiviral medication due at 9:00 am was missing from the medication cart. Additionally, the resident refused to take a Fortified Nutritional Shake, which the LPN subsequently poured down the sink and discarded the cup. Further review of the Medication Administration Audit Record revealed discrepancies in the documentation. The LPN signed off the antiviral medication as administered at 11:43 am, which was 1 hour and 43 minutes past the scheduled time. The Fortified Nutritional Shake was also signed off as given, despite the resident's refusal and the LPN's disposal of the shake. During an interview, the DON acknowledged the errors and noted that the Pyxis system was available for medication dispensing, although it was unclear if the antiviral medication was stocked there. The DON also stated that any medication not administered should be documented as such, and the physician and responsible party should be informed.
Expired Medications Not Discarded in Medication Storage Room
Penalty
Summary
The facility staff failed to discard expired medications in one of the four medication storage rooms assessed during the survey. During an observation of the medication storage room on the Evergreen unit, the surveyor found several expired items, including three intravenous bags of 10% Dextrose, an Infuvite Adult Multiple vitamin vial, a Biopatch Protective Disk, and a Thick & Easy Clear Drink. These items had expiration dates ranging from March 2024 to October 2024. The Nurse Unit Manager was informed of these findings and subsequently discarded the expired items. Interviews with the Evergreen Unit Clerk and Central Supply Personnel revealed a lack of clarity and responsibility regarding the management of expired medications. The Evergreen Unit Clerk stated that she occasionally checks for expiration dates, but primarily relies on central supply personnel for restocking and removing expired items. Conversely, the Central Supply Personnel indicated that she restocks the medication supply room but does not handle expired items, considering it the responsibility of the nurse or nurse manager. This miscommunication and lack of defined roles contributed to the oversight in managing expired medications.
Deficiency in Annual Dementia Training for GNAs
Penalty
Summary
The facility staff failed to ensure that geriatric nursing assistants (GNAs) received annual dementia training, as evidenced by the lack of documentation in the files of four GNAs. During a review of employee files, it was found that there was no confirmation of completed dementia training within the last 12 months for these GNAs. The facility's educator, who assumed the role in July 2024, stated that annual competencies, including dementia training, are typically conducted in April. However, she was unable to provide verification of the training due to the transition from paper documentation to an electronic system. The facility's administrator acknowledged an issue with employee education records not being properly filed by the previous educator, which resulted in incomplete education files. This issue was identified during a quality assessment performance improvement meeting in September 2024. The facility is in the process of implementing a new virtual education software to address the documentation challenges. Despite these efforts, the deficiency in ensuring annual dementia training for GNAs was evident during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Towson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holly Hill Healthcare Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Towson Rehabilitation And Healthcare Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Greater Baltimore Medical Center Sub Acute Unit | 1.3 mi | — | 0 | 0 |
| Edenwald | 1.4 mi | ★★★★★ | 3 | 0 |
| Pickersgill Retirement Community | 1.5 mi | ★★★★★ | 6 | 0 |
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